Form OWCP-1168 Provider Enrollment Form

Provider Enrollment Form

1240-0021_OWCP-1168 - Provider Enrollment form_Nonsub_20230120

Provider Enrollment Form

OMB: 1240-0021

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 1240-0021 can be found here:

2023-10-03 - Revision of a currently approved collection

Document [pdf]

Download: pdf | pdf

Provider Enrollment Form

U.S. Department of Labor

Reset

Office of Workers’ Compensation Programs

OMB Number 1240-0021
Expires: 12/31/2023
1. Are you applying for a new enrollment or updating your record?
Re-Enrollment

New Enrollment

Re-Validation

Update

1a. If Update, Re-Enrollment or Re-Validation,
Enter Provider ID or Federal Employer Identification Number (FEIN)
PART A: BASIC INFORMATION (Required)
2. Enrollment Type
Individual
Group Practice (Please see Page 9 for completion of group practice enrollment)
Facility/Agency/Organization/Institution
3. Provider Type Select
(For multi-specialty group provider, select primary provider type)
If you select “Other Provider” (96) or Non-Medical Vendor (53)
3a. Please explain
4. Program
DFEC

DCMWC

DEEOIC

DLHWC
Reset

5. Individual Information (If you enroll using SSN)
5a. Last Name

5c. Middle Name

5b. First Name

5d. SSN

6. Organization Information
6a. Organization Name
(Legal Business Name)
6b. Organization Business Name
(Doing Business As)

6c. FEIN

7. National Provider Identifier (NPI)
8. Entity Type Select
8a. If Other, please explain
9. Email Address
10.

I do not wish to be included in an online searchable list of OWCP providers.

10a. Reason

Previous editions unusable

OWCP-1168
(Revised 04/20)
Page 1

PART B: LOCATION (Required)
11. Location Contact Information
11a. Business Name
11b. Contact Last Name

11c. Contact First Name

11d. Phone Number

11e. Fax Number

11f. Email Address
12. Physical Address
12a. Address Line 1
Address Line 2
Address Line 3

12b. City/Town

12c.State/Province Select

12e. County

12f. Country

13. Mailing Address

12d. Zip Code

Same as Physical Address

13a. Address Line 1
Address Line 2
Address Line 3
13c. State/Province Select

13b. City/Town

13e. County

13d. Zip Code

13f. Country

PART C: TAXONOMY
14. Taxonomy
Code(s)

Previous editions unusable

OWCP-1168
(Revised 04/20)
Page 2

PART D: OWNERSHIP DETAILS (Optional)

Reset

15. Organization Owner
15a. Organization Name

15b. FEIN

16. Individual Owner
16a. Last Name

16b. First Name

16c. SSN

17. Address
17a. Address Line 1
Address Line 2
Address Line 3
17b. City/Town

17c. State/Province Select

17e. County

17f. Country

17d. Zip Code

Additional Ownership Information
Reset

18. Organization Owner
18a. Organization Name

18b. FEIN

19. Individual Owner
19a. Last Name

19b. First Name

19c. SSN

20b. City/Town

20c. State/Province Select

20d. Zip Code

20e. County

20f. Country

20. Address
20a. Address Line 1
Address Line 2
Address Line 3

Previous editions unusable

OWCP-1168
(Revised 04/20)
Page 3

PART E: LICENSE AND CERTIFICATION - (Required for Individual and Facility/Agency/Organization enrollment types.)
Group practice providers may skip Section E through I and go to Addendum 1.
21a. License/Certification Category Select

21b. Name

21c. License/Certification Type

21d. License/Certification Number

21e. Initial Issue Date

21f. Expiration Date

21g. Issued State Select

21h. Issuer Agency

21i. Web Link

21j.

License/Certification not required by State.

21k. Please explain

Additional License/Certification
22a. License/Certification Category Select

22b. Name

22c. License/Certification Type

22d. License/Certification Number

22e. Initial Issue Date

22f. Expiration Date

22g. Issued State Select

22h. Issuer Agency

22i. Web Link

Previous editions unusable

OWCP-1168
(Revised 04/20)
Page 4

PART F: IDENTIFIERS
23. Provider Identifier Information
23a. Identifier Type Select

23b. Identifier Value

23c. Start Date

23d. End Date

24. Additional Provider identifier information
24a. Identifier Type Previous Provider ID
24c. Start Date

24b. Identifier Value
24d. End Date

PART G: SUBMISSION METHOD
25. Mode of Submission. Check all applicable
Billing Agent/Clearinghouse

Web Interactive

Web Batch

None

FTP Secured Batch

PART H: EDI SUBMITTER DETAILS
26. Billing Agent/Clearinghouse/Submitter Information
26a. Billing Agent/Clearinghouse OWCP ID
26b. Start Date

Previous editions unusable

26c. End Date

OWCP-1168
(Revised 04/20)
Page 5

PART I: EDI CONTACT DETAILS

27. EDI Contact Information

27a. Contact Title

27b. Last Name

27c. First Name

27d. Phone Number

27e. Fax Number

27f. Email Address

28. Address
28a. Address Line 1
Address Line 2
Address Line 3

28b. City/Town

28c. State/Province Select

28e. County

28f. Country

28d. Zip Code

29. Additional EDI Contact Information
29a. Contact Title

29b. Last Name

29c. First Name

29d. Phone Number

29e. Fax Number

29f. Email Address

30. Address
30a. Address Line 1
Address Line 2
Address Line 3

30b. City/Town

30c. State/Province Select

30e. County

30f. Country

Previous editions unusable

30d. Zip Code

OWCP-1168
(Revised 04/20)
Page 6

Privacy Act Statement
Collection of this information by OWCP is necessary for its administration of the Federal Employees’ Compensation Act, the
Black Lung Benefits Act, the Longshore and Harbor Workers’ Compensation Act and the Energy Employees Occupational
Illness Compensation Program Act, and is authorized under 20 CFR 10.800, 20 CFR 30.700, 20 CFR 702.145, 20 CFR
725.714 and 33 USC 918(b). The information provided will be used to ensure accurate payment of medical and vocational
rehabilitation provider bills and is protected by the Privacy Act of 1974, as amended (5 USC 552a) in accordance with the
following systems of records: DOL/GOVT-1, DOL/OWCP-4 DOL/OWCP-9 and DOL/OWCP-11, published in the Federal
Register, Vol. 81, page 25766, April 29, 2016, or as updated and republished. Completion and submission of this form is
voluntary; however, failure to provide the information (including SSN or FEIN) will result in substantially delayed payment
of bills.

This information will be furnished to OWCP and its data processing contractors and may also be disclosed to

other federal and state agencies in connection with the administration of other programs, to the Department of Justice for
litigation purposes, and to medical and other provider review boards. Additional disclosures may be made through the routine
uses for information contained in the referenced systems of records.
Public Burden Statement
Under the Paperwork Reduction Act., persons are not required to respond to a collection of information unless such
collection displays a valid OMB control number. We estimate that it will take an average of 30 minutes to complete this
information collection, including time for reviewing the instructions, searching existing data sources, gathering and
maintaining the data needed, and completing and reviewing the information. If you have any comments regarding these
estimates or any other aspect of this collection including suggestions for reducing this burden, send them to the U.S.
Department of Labor, Office of Workers' Compensation Programs, Room S-3524, 200 Constitution Avenue, N.W.,
Washington, D.C. 20210. DO NOT SEND THE COMPLETED FORM TO THE ABOVE ADDRESS.
Notice
If you have a substantially limiting physical or mental impairment, Federal disability nondiscrimination law gives you the right to
receive help from OWCP in the form of communication assistance, accommodation and modification to aid you in the claims
process. For example, we will provide you with copies of documents in alternate formats, communication services such as
sign language interpretation, or other kinds of adjustments or changes to account for the limitations of your disability. Please
contact our office or the claims examiner to ask about this assistance.
Disclosure Statement
Within ten years of the date of this statement have you or any individual listed on this application had an action related to fraud
or abuse in a government program taken against him or her resulting in (1) a felony or misdemeanor conviction; (2) a liability
finding in civil proceedings; or (3) a settlement entered in lieu of conviction?

Yes

If Yes, provide details including type of action, Agency undertaking adverse action and date of action.

Required for DFEC providers
For Provider Type “Medical Supplies/Durable Medical Equipment (DME) / Prosthetics / Orthotics” (75) only:
Are you an accredited DMEPOS supplier enrolled with Medicare?

Yes

If Yes, provide the phone number that you used in your Medicare DMEPOS enrollment.

Previous editions unusable

OWCP-1168
(Revised 04/20)
Page 7

Confirm and Sign
I, the undersigned, certify to the following: I have read the contents of this application, and the information contained herein is
true, correct, and complete.
I certify that I and my agents have currently in effect all necessary licenses, certifications, approvals, insurance,
etc. required to properly provide the services and/or supplies for the OWCP in the state, county, locality, or jurisdiction
where the services and/or supplies are provided. I will provide proof of such licenses, certifications, approvals,
insurance, etc.

upon

the

OWCP's

request.

I understand that any

revocation,

withdrawal,

non-renewal

necessary license, certification, approval, insurance, etc. required for me to properly provide services, shall be grounds for
termination of enrollment/registration by the OWCP.
I authorize the OWCP to verify the information contained herein. I agree to notify the OWCP of any change in ownership,
practice location and/or Final Adverse Action involving fraud or abuse within 30 days of the reportable event. In addition, I agree to
notify the OWCP of any other changes to the information in this form within 90 days of the effective date of change.
I also certify that I am not currently sanctioned, suspended, debarred or excluded by any Federal or State Health Care
Program, (e.g., Medicare, Medicaid, or any other Federal program), or otherwise prohibited from providing services to Medicare,
Medicaid, or other Federal program beneficiaries nor are any owners, officers, or managing employees of the practice
listed in this application.
I understand that any deliberate omission, misrepresentation, or falsification of any information contained in this application
or contained in any communication supplying information to the Department of Labor, Office of Workers’ Compensation
Program (OWCP), or any deliberate alteration of any text on this application form, may be punished by criminal, civil, or
administrative penalties including, but not limited to, the denial or revocation of OWCP billing privileges, civil damages, and/or
imprisonment.
I agree to abide by the OWCP regulations and program instructions that apply to me or to the organization listed in Section 3A of
this enrollment form. I understand that payment of a claim by OWCP is conditioned upon the claim and the underlying
transaction complying with state and federal laws (including, but not limited to, the Federal anti-kickback statute) and OWCP
regulations, and program instructions.
I have completed an ACH Vendor Payment/Electronic Fund Transfer (EFT) form.
Print Name and Title

Signature

Print, sign and mail or fax form to the following address:
Provider Enrollment
Department of Labor - OWCP
P. O. Box 8312
London, KY 40742-8312
Fax: 888-444-5335

Date

Addendum 1: Individual Providers Information for Group Practice Enrollment (Part A)
Fill in this addendum to add, update or remove servicing providers for Group Practice as applicable.
•

Reviewer will validate NPI for all servicing providers.

•

Reviewer will also validate license and certificate for 9 or less servicing providers. For more than 9 providers, group is
responsible for validating license and certificate.
Reset

2. Individual Information (Applicable if enrolling using SSN)

1.
Add

2a. Last Name

2c. Middle Name

2b. First Name

2d. SSN

Update
Remove
3.

Organization Information (Applicable if enrolling using FEIN)

3a. Organization Name
3b. Organization Business Name

3c. FEIN

4. Provider Type Select

5. NPI

6. Taxonomy a.

7. License/Certification Information
License/
Certification
Category

Select

License/
Certification
Number

License/Certification Type

Issued
State

Initial Issue
Date

Expiration
Date

Others

ense/

Select

Additional Addendum Information
1.

Reset

2. Individual Information (Applicable if enrolling using SSN)
Add

2a. Last Name

2c. Middle Name

2b. First Name

2d. SSN

Update
Remove
3.

Organization Information (Applicable if enrolling using FEIN)

3a. Organization Name
3c. FEIN

3b. Organization Business Name
4. Provider Type Select

5. NPI

6. Taxonomy a.

7. License/Certification Information
License/
Certification
Category

License/Certification Type

License/
Certification
Number

Issued
State

Select

Previous editions unusable

Initial Issue
Date

Expiration
Date

OWCP-1168
(Revised 04/20)
Page 9

Addendum 2: Taxonomy Information (Part C)
Type or print additional Taxonomy information as applicable.
Use additional sheet(s) as required.

Taxonomy

Previous editions unusable

OWCP-1168
(Revised 04/20)
Page 10

Addendum 3: License and Certification (Part E)
Type or print additional license and certification information as applicable.
Use additional sheet(s) as required

1. License/Certification Category Select

2. Name

3. License/Certification Type

4. License/Certification Number

5. Initial Issue Date
7. Issued State Select

6. Expiration Date

8. Issuer Agency

9. Web Link
1. License/Certification Category Select
3. License/Certification Type

5. Initial Issue Date
7. Issued State Others

2. Name

4. License/Certification Number

6. Expiration Date

8. Issuer Agency

9. Web Link
1. License/Certification Category Select
3. License/Certification Type

5. Initial Issue Date
7. Issued State Select

2. Name

4. License/Certification Number

6. Expiration Date

8. Issuer Agency

9. Web Link

Previous editions unusable

OWCP-1168
(Revised 04/20)
Page 11

Addendum 4: Billing Agent/Clearinghouse Provider ID (Part H)
Type or print additional Billing Agent/Clearinghouse Provider IDs as applicable.
Use additional sheet(s) as required.

Billing Agent/Clearinghouse ID

Previous editions unusable

Start Date

End Date

OWCP-1168
(Revised 04/20)
Page 12

Instructions
A brief description of each data element is listed below. Be sure to sign and date the form when you submit it.
Part A: Basic Information

Indicate whether this form is being used for a New Enrollment, to Update an
existing ACTIVE enrollment record, for a Re-Enrollment (previously enrolled
provider was excluded, now has become re-eligible) or to Re-Validate currently
enrolled but EXPIRED enrollment record.

If the form is being submitted to Update, Re-Enrollment or Re-Validate your
record, enter your Provider Number or Federal Employer Identification Number.
1a.

•

For Re-Validation and Re-Enrollment, complete all applicable sections,
sign and send the form.

•

For Update, complete ONLY changed sections, sign and send the form.

Required

Required if Update, ReEnrollment or Re-Validate
option is selected in 1

Select Enrollment Type:
Individual
•

Any provider who is eligible to receive a Type I National Provider
Identifier (NPI) through the National Plan and Provider Enumeration
System (NPPES). Providers eligible to receive an NPI are those who
deliver medical or health services, as defined under Section 1861(s) of
the Social Security Act, 42 U.S.C. 1395x(s).

•

Individuals providing only non-medical services, attendant care, or
personal care services, who do not need an NPI.

Group Practice

•

One or more health care practitioners who practice their profession at a
common location (whether or not they share common facilities, common
supporting staff, or common equipment) and have formed a partnership
or corporation or are employees of a person, partnership or corporation,
or other entity owning or operating the health care facilities at which they
practice. These entities have a Type II National Provider Identifier (NPI)
from the National Plan and Provider Enumeration System (NPPES).

•

Fill out the appropriate parts in Addendum 1 of the form for each
professional that will be providing services under the group Provider
Number (Name, Social Security number, Provider Type Code from list
below, NPI, DEA Number, Taxonomy, License or Certificate Type,
License Number, Issue Date, Issue State and Expiration Date of current
license). Continue additional sheet(s) as needed.

Required
Refer to Appendix 2 for more
information

Facility/Agency/Organization/Institution
•

An Inpatient or Outpatient Hospital, a Skilled Nursing Facility, an
Intermediate Care Facility, a Clinic (RHC, FQHC, Hospital Based Clinic,
Urgent Care), a Psychiatric Facility, a Mental Institution, a Durable
Medical Equipment Supplier, a Free Standing Ambulatory Surgical
Center, a Long Term Care Facility, an Independent Clinical Laboratory, a
Free Standing Radiology, a Dialysis Center, a Pharmacy, a Partnership,
a Corporation, or any other entity that furnishes or arranges for the
furnishing of services for which payment is billed under the OWCP
programs. It does not include individual practitioners or groups of
practitioners. In addition, you must also be eligible to receive and
currently possess, a Type II National Provider Identifier, available
through the National Plan and Provider Enumeration System (NPPES).

•

Any entity other than individual who does not deliver medical care or
health services and is thus ineligible for a National Provider Identifier

Previous editions unusable

OWCP-1168
(Revised 04/20)
Page 13

(NPI) available through the National Plan and Provider Enumeration
System (NPPES). This provider type can include Fiscal Intermediaries,
Non-Emergency Transportation, etc.
Type or print Provider Type

3a.

Required

For Group Practice, type or print primary Provider Type.

Refer to Appendix 1 for more
information

Type or print explanation for Provider Type

Required if 53 or 96 is selected
in 3.
Required

Check the Program(s) in which you want to enroll as a provider. If mailing, please
mail the application to P.O. Box as indicated on Page 8 of the application or fax a
separate document.

Type or print Individual information

Required if enrolled using SSN

5a.

Type or print provider’s Last Name

Required

5b.

Type or print provider’s First Name

Required

5c.

Type or print provider’s Middle Name

5d.

Type or print SSN

Required

Type or print Organization information

Required if enrolled using FEIN

6a.

Type or print Organization Name (i.e.) Legal Business Name

Required

6b.

Type or print Organization Business Name (i.e.) Doing Business As

Required

6c.

Type or print FEIN

Required

Type or print NPI

Refer to Appendix 3 for
requirements

Refer to Appendix 3 for more
information

Type or print IRS W9 Entity Type. Select from following values:

•

C Corporation

•

S Corporation

•

Individual/Sole Proprietor or single-member LLC

•

LLC Filing as C Corporation

•

LLC Filing as S Corporation

•

LLC Filing as Partnership

•

LLC Filing as Sole Proprietor

•

Others

•

Partnership

Required

8a.

Type or print Reason

Type or print Email Address

Previous editions unusable

Required if selected Others in 8

OWCP-1168
(Revised 04/20)
Page 14

10.

Select this option if you do not wish to be included in the OWCP online
searchable program. However, selecting this option will not exclude your
information in a FOIA (Freedom Of Information Act) request.

10a.

Type or print Explanation

Required if checkbox is selected
in 10

Part B: Location Information
Providers offering services at different location(s) are required to enroll
separately for each location. Servicing providers under a group practice are not
required to enroll separately.
11.

Location Contact information

Required

11a.

Type or print location Business Name

Required

11b.

Type or print contact Last Name

Required

11c.

Type or print contact First Name

Required

11d.

Type or print Phone number

Required

11e.

Type or print Fax number

11f.

Type or print Email Address

12.

Type or print Physical Address
12a.

Type or print street Address Line 1

Required

Type or print street Address Line 2
Type or print street Address Line 3
12b.

Type or print City or Town

Required

12c.

Type or print State or Province

Required for domestic address

12d.

Type or print Zip (or postal) Code

Required

12e.

Type or print County

12f.

Type or print Country

Required for foreign address

Select this option if the mailing address is same as the physical address.
Otherwise print or type Mailing Address

13.
13a.

Type or print street Address Line 1
Type or print street Address Line 2
Type or print street Address Line 3

13b.

Type or print City or Town

13c.

Type or print State or Province

Previous editions unusable

OWCP-1168
(Revised 04/20)
Page 15

13d.

Type or print Zip (or postal) Code

13e.

Type or print County

13f.

Type or print Country

Part C: Taxonomy

Type or print Taxonomy
Use Addendum 1 for taxonomy for servicing providers

14.

Use Addendum 2 for additional taxonomy codes. Use additional sheet(s)

Refer to Appendix 3 for
requirements

as required.

Part D is optional .

Part D: Ownership Details

Type or print Organization Ownership information

15.
15a.

Type or print Organization Name

15b.

Type or print FEIN

16.

Type or print Individual Ownership information
16a.

Type or print individual Last Name

16b.

Type or print individual First Name

16c.

Type or print SSN

17.

For DFEC and DEEOIC
providers, list any business
with more than a 5% interest
in or where involvement is at
an officer, director or agent of
the company

If enrolling using FEIN

If enrolling using SSN

Type or print Ownership address
17a.

Type or print street Address Line 1
Type or print street Address Line 2
Type or print street Address Line 3

17b.

Type or print City or Town

Previous editions unusable

OWCP-1168
(Revised 04/20)
Page 16

17c.

Type or print State or Province

17d.

Type or print Zip (or postal) Code

17e.

Type or print County

17f.

Type or print Country

For domestic address

For foreign address only

Section 18 to 20 are for additional ownership information, use additional
sheets as required
18.

Refer to instructions for Section 15

If additional sheets needed

19.

Refer to instructions for Section 16

If additional sheets needed

20.

Refer to instructions for Section 17

If additional sheets needed

Part E: License and Certification

21.

•

Please provide all license/certification required by your State to perform the
service under your Provider Type.

•

If a license or certification is not required by the State, attach letter/
evidence from the State authority.

•

OWCP will verify all your license/certification with your State's license
issuer agency before your enrollment can be approved.

•

After your enrollment is approved, you are responsible to keep your
license/certification information up to date.

•

Expired license/certification will cause the termination of the provider
status.

•

If you have a renewed license/certification under a different number, please
make sure to enter it using the exactly same License/Certification Type.

•

Use Addendum 1 for license and certification information of servicing
providers for group practice enrollment.

•

Refer to Addendum 3 to add additional license and certification information.
Use additional sheet(s), as required.

Refer to Appendix 3 for
requirements

Type or print license or certification category from following options:
21a.

•

License

•

certification

Required

21b.

Type or print Name

Required

21c.

Type or print License or Certification Type

Required

21d.

Type or print License or Certification Number

Required

Previous editions unusable

OWCP-1168
(Revised 04/20)
Page 17

21e.

Type or print License or Certification Initial Issue Date

Required

21f.

Type or print License or Certification Expiration Date

Required

21g.

Type or print License or Certification Issued State

Required

21h.

Type or print License or Certification Issuer Agency

Required

21i.

Type or print License or certification Web Link

Required

21j.

Select this option if License or Certification is not required by State

21k.

Type or print Explanation

Required if 25j. is selected

Additional License and Certification information. Refer to instructions for section 21.
Use additional sheet(s) as required.

22.

Part F: Identifiers

23.

Medicare number is required for
hospitals (Provider type: 01, 02,
03)

Identifier information

Type or print Identifier Value from below list of values:

23a.

24.

•

DEA Number

•

NPI

•

Other Provider ID

•

Previous Provider ID

•

Provider Medicare Number

•

United Mine Workers of America (UMWA) Number

Required

23b.

Type or print Identifier Value

Required

23c.

Type or print Start Date

Required

23d.

Type or print End Date
Additional Identifier information. Refer to instructions for section 23. Use
additional sheet(s) as required.

Part G: EDI Submission Method

Select mode of Submission. Select all applicable options:
25.

Billing
Agent/Clearinghouse

For providers who use a 3rd party to bill.

Web Interactive

For entering (keying) bills directly in the System.

Previous editions unusable

OWCP-1168
(Revised 04/20)
Page 18

FTP Secured Batch:

For submitting files via an SFTP site.

Web Batch

For upload/download of files in the system.

None

For submissions through paper form ONLY.

•

"Web Batch" method is often used by providers who submit their own
HIPAA batch transactions. It allows a maximum file size of 50 MB.

•

Your EDI submission method is "FTP Secured Batch" if you submit
and retrieve batches at a secure web folder assigned to you by
OWCP. This method was designed with clearinghouses and billing
agents in mind. It allows a maximum file size of 100 MB.

•

Don't select “None” if other submission method is selected. You can
always submit paper form in addition to EDI Submission.

Part H: EDI Submitter Details

Billing Agent/Clearinghouse information

26.

•

Your Billing Agent/Clearinghouse must be enrolled with OWCP first.

•

Please obtain the Billing Agent/Clearinghouse’s OWCP ID to complete
this section.

•

If they are not yet enrolled, you can still complete your enrollment by
temporarily choosing not to use Billing Agent/Clearinghouse.

•

You can add them later after they are enrolled with OWCP.

Required if Billing
Agent/Clearinghouse selected in
Part G

Refer to Addendum 4 for additional information. Use additional sheet(s) as
required.
26a.

Type or print Billing Agent/Clearinghouse OWCP ID

Required

26b.

Type or print Start Date

Required

26c.

Type or print End Date

Part I: EDI Contact Details

EDI Contact information

Required if FTP Secured Batch
or Web Batch is selected in Part
G

27a.

Type or print Contact Title

Required

27b.

Type or print contact last name

Required

27c.

Type or print contact First Name

Required

27d.

Type or print contact Phone number

Required

27.

Previous editions unusable

OWCP-1168
(Revised 04/20)
Page 19

27e.

Type or print contact Fax number

27f.

Type or print contact Email Address

28.

Type or print Contact Address
28a.

Type or print street Address Line 1

Required

Type or print street Address Line 2
Type or print street Address Line 3
28b.

Type or print City or Town

Required

28c.

Type or print State or Province

Required for domestic address

28d.

Type or print Zip (or postal) Code

Required

28e.

Type or print County

28f.

Type or print Country

29.

Additional EDI Contact information. Refer to instructions for Section 27

30.

Additional EDI Contact address. Refer to instructions for Section 28

Addendum 1: Servicing Providers Information

Required for foreign address

Required for enrollment type
Group Practice

Select one option to add, update or remove a servicing provider:

•

For New Enrollment, only Add action can be selected.

•

Type or print all the information for New and Update Action.

•

Type or print SSN or FEIN for Remove Action.

•

Servicing providers can be enrolled using SSN (individual) or FEIN
(organization).

Required

Type or print Individual information

Required if enrolled using SSN

2a.

Type or print Last Name

Required

2b.

Type or print First Name

Required

2c.

Type or print Middle Name

2d.

Type or print SSN

Required

Type or print Organization information

Required if enrolled using FEIN

3a.

Type or print Organization Name

Required

3b.

Type or print Organization Business Name

Required

3c.

Type or print FEIN

Required

Previous editions unusable

OWCP-1168
(Revised 04/20)
Page 20

Required
4.

Type or print Provider Type

Type or print NPI

Refer to Appendix 3 for
requirements

Type or print Taxonomy

Refer to Appendix 3 for
requirements

Type or print License/Certification information

Refer to Appendix 3 for
requirements

Refer to Appendix 1 for more
information

Type or print License or Certification Category from following options:
•

License

•

certification

Required

Type or print License or Certification Type

Required

Type or print License or Certification Number

Required

Type or print License or certification Issued State

Required

Type or print License or certification Initial Issue Date

Required

Type or print License or certification Expiration Date

Required

Addendum 2: Taxonomy

Refer to Part C instructions

Addendum 3: License and Certification

Refer to Part E instructions

Addendum 4: Billing Agent/Clearinghouse

Refer to Part H instructions

Supporting Documents

Required, please attach copy of
the applicable supporting
document(s)

ACH Form

Required

Copy of License/Certification

Required if you provided
License/Certification information
in Part E

File Type	application/pdf
File Title	OWCP
Subject	111
Author	Kannabiran
File Modified	2023-01-20
File Created	2018-12-10