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Provider Enrollment Form
Provider Enrollment Form
OMB: 1240-0021
IC ID: 38462
OMB.report
DOL/OWCP
OMB 1240-0021
ICR 202301-1240-005
IC 38462
( )
Documents and Forms
Document Name
Document Type
Form OWCP-1168
Provider Enrollment Form
Form and Instruction
Form OWCP-1168
Provider Enrollment Form
Form and Instruction
OWCP-1168 Provider Enrollment Form
1240-0021_OWCP-1168 - Provider Enrollment form_Nonsub_20230120.pdf
owcpmed.dol.gov/portal/resources/forms-and-references/general
Form and Instruction
Information Collection (IC) Details
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