OWCP-1168 Provider Enrollment Form

Provider Enrollment Form

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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?
New Enrollment

Re-Enrollment

Re-Validation

1a. If Update, Re-Enrollment or Re-Validation,

Update (For Update, ONLY complete sections
you wish to change, then Confirm and
Sign on page 8)

Enter Provider ID or Federal Employer Identification Number (FEIN)
PART A: BASIC INFORMATION (All fields in this section are required; if "other" is selected, explanation is required.)
2. Enrollment Type (Refer to Instructions for additional information)
Individual
Group Practice (Please see Page 9 - Addendum 1, for completion of group practice enrollment for each
professional) Facility/Agency/Organization/Institution
3. Provider Type Select
(For multi-specialty group provider, select primary provider type. Refer to Appendix 1 & 3 for more information)
If selecting “Other Provider” (96) or Non-Medical Vendor (53), please complete 3a.:
3a. Please explain
4. Program (Check the Program(s) in which you want to enroll as a provider.)
DFEC

DCMWC

DEEOIC

DLHWC
Reset

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

5c. Middle Name

5b. First Name

5d. SSN

6. Organization Information (If enrolling using FEIN)
6a. Organization Name
(Legal Business Name)
6b. Organization Business Name
(Doing Business As)

6c. FEIN

7. National Provider Identifier (NPI)
(Refer to Appendix 3)
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

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PART B: LOCATION (All fields are required. If not applicable specify N/A)
11. Location Contact 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.)
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
13b. City/Town

13c. State/Province Select

13e. County

13d. Zip Code

13f. Country

PART C: TAXONOMY (Required if applicable.)
14. Taxonomy
Code(s)

a.

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b.

c.

d.

e.

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PART D: OWNERSHIP DETAILS (Optional. Refer to Instructions for additional information.)

Reset

15. Organization Owner (If enrolling using FEIN)
15a. Organization Name

15b. FEIN

16. Individual Owner
16a. Last Name

16b. First Name

16c. SSN

17. Address (If enrolling using SSN)
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 (Section 18 to 20 are for additional ownership information. Use additional sheets as required)
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

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PART E: LICENSE AND CERTIFICATION (Required for Individual and Facility/Agency/Organization enrollment types.
Please refer to Instructions on page 14 for additional information.)
Group practice providers may skip Sections E and F, and continue at Section G through 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. (Select if License/Certification is not required by State)

21k. Please explain
Additional License/Certification (Use additional sheet(s) as required)
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

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PART F: IDENTIFIERS
23. Provider Identifier Information (Medicare number is required for hospitals (Provider type: 01, 02, 03))
23a. Identifier Type Select
23c. Start Date

23b. Identifier Value
23d. End Date

24. Additional Provider identifier information (Use additional sheet(s) as required)
24b. Identifier Value

24a. Identifier Type Select
24c. Start Date

24d. End Date
PART G: EDI SUBMISSION METHOD

25. Mode of Submission. Check all applicable (See Instructions on page 15 for details regarding modes of submission)
Billing Agent/Clearinghouse

Web Interactive

Web Batch

None

FTP Secured Batch

PART H: EDI SUBMITTER DETAILS (Required if Billing Agent/Clearinghouse selected in Part G)
26. Billing Agent/Clearinghouse/Submitter Information (See Instructions for further details.)
26a. Billing Agent/Clearinghouse OWCP ID
26b. Start Date

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26c. End Date

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PART I: EDI CONTACT DETAILS (Required if submitting EDI)
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

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30d. Zip Code

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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 25 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

No

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

No

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

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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, or non-renewal of 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. (Please attach ACH form)

Print Name and Title

Signature

Date

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

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Addendum 1: Servicing Providers Information for Group Practice Enrollment
(All fields are required for providers enrolled as Group Practice. Refer to Instructions and Appendices 1 and 3 for additional
information.)
Fill in this addendum to add, update or remove servicing providers for Group Practice. Use additional sheet(s) as required.

2. Individual Information (If enrolling using SSN)

1.
Add

Reset

2a. Last Name

2c. Middle Name

2b. First Name

2d. SSN

Update
Remove

3.Organization Information (If enrolling using FEIN)
3a. Organization Name
3b. Organization Business Name

3c. FEIN

4. Provider Type Select

5. NPI

6. Taxonomy a.

b.

c.

d.

e.

7. License/Certification Information
License/
Certification
Category

Select

License/
Certification
Number

License/Certification Type

Issued
State

Initial Issue
Date

Expiration
Date

Others

ense/

Select

Select

Additional Addendum Information
1.
Add
Update
Remove
3.

Reset

2. Individual Information (Applicable if enrolling using SSN)
2a. Last Name

2c. Middle Name

2b. First Name

2d. SSN

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.

b.

c.

d.

e.

7. License/Certification Information
License/
Certification
Category

License/Certification Type

License/
Certification
Number

Issued
State

Select

Select

Select

Select

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Initial Issue
Date

Expiration
Date

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

Taxonomy

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Addendum 3: License and Certification
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

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

Billing Agent/Clearinghouse ID

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Start Date

End Date

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Instructions
A brief description and additional information for parts of the form is listed below. Be sure to sign and date the form when you submit it.
Part A: Basic Information
New Enrollment - New Providers select when not previously enrolled with OWCP
1.

Re-Enrollment - Previously enrolled Provider was excluded, now has become
eligible to enroll with OWCP

Required

Re-Validate - Current Provider who is enrolled with OWCP but has expired
information on the provider enrollment record.
Update - Current Provider who is enrolled with OWCP and needs to update
existing information on the provider enrollment record
Select Enrollment Type:
2.

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).

Required
Refer to Appendix 2 for more
information

Facility/Agency/Organization/Institution

10.

•

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
(NPI) available through the National Plan and Provider Enumeration
System (NPPES). This provider type can include Fiscal

•

Intermediaries, Non-Emergency Transportation, etc.

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.

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Part C: 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 provider
type taxonomy requirements

as required.

Part D is optional.

Part D: Ownership Details
(OPTIONAL)

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

Part E: License and Certification
•

Please complete and attach copies of 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 exact same License/Certification Type.
•

21.

•

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.

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

21k.

•

License

•

certification

Type or print Explanation and attach letter/evidence from State authority

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Required for Individual and
Facility/Agency/
Organizational enrollment
types.

Refer to Appendix 3 for
requirements

If submitting a copy of your
licenses and/or certifications
skip 21b through 21i
Required if 21j. is selected

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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.

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.

Addendum 1: Servicing Providers Information

Required for enrollment type
Group Practice

Select one option to add, update or remove a servicing provider:
1.

•

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).

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Required

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Appendix 1: Provider/Hospital Type Codes
01

General Hospital

63

Optician

02

Special Hospital/ Rehabilitation Facility

65

Home Health Agency

03

Psychiatric Hospital

66

Rural Health Clinic

05

Community Mental Health Center

67

DMA Consult Contractor

20

Pharmacy

68

Federally Qualified Health Center

25

Physician (MD) & Physician (DO)

69

Birthing Center

27

Podiatrist

70

Health Maintenance Organization or

28

Chiropractor

Preferred Health Plan

29

Physician Assistant

71

Physical Therapist

30

Advanced Registered Nurse Practitioner

72

Occupational Therapist

(ARNP)

73

Pulmonary Rehabilitation

Certified Registered Nurse Anesthetist

74

Outpatient Renal Dialysis Facility

(CRNA)

75

Medical Supplies/Durable Medical

31

Equipment (DME) /Prosthetics/Orthotics

32

Psychologist

33

Contract Medical Consultant

76

Case Management Agency

34

Licensed Midwife

77

Social Worker

35

Dentist

78

Blood Bank

36

Registered Nurse (RN)

80

Pay-to-Intermediary

37

Licensed Practical Nurse (LPN)

88

Ambulatory Surgery Center

38

Nursing Attendant

89

Federal Facility (VA Hospital)

40

Ambulance

90

Skilled Nursing Facility (SNF)-Medicare

41

Contract Nurse

42

Air/Water Ambulance Company

92

Intermediate Care Facility (ICF)

43

Taxi

93

Rural Hospital Swing Bed

44

Public Transportation & Private

94

Boarding House

Transportation

95

Insurance Company (Third party Carriers)

46

Hospice

96

Other Provider

47

FOH-DMA Providers

97

Billing Agent

50

Independent Laboratory

98

Lien Holder

51

Portable X-Ray Company

52

Alternative Medicine (e.g., Massage

Certified & Non-Medicare Certified

Therapist/Acupuncturist)
53

Non-Medical Vendor

55

Vocational Rehabilitation (Training, Tuition
and Schools)

56

Vocational Rehabilitation Counselor

57

Rehabilitation Maintenance

58

Assisted Re-employment

59

Relocation Expenses

60

Audiologist/Speech Pathologist

61

Second Opinion Contractor

62

Optometrist

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Appendix 2: Enrollment Type/Provider Type
Applicable provider types for each enrollment type are listed:
Enrollment Type

Provider Type

Individual

25, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 40, 41, 42, 43, 44, 47, 50, 51,
52, 53, 55, 56, 57, 58, 59, 60, 61, 62, 63, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74,
75, 76, 77, 78, 80, 88, 95, 96, 98

Group Practice

25, 27, 28, 29, 30, 31, 32, 34, 35, 36, 37, 38, 43, 52, 60, 62, 63, 65, 66, 68, 69,
70, 71, 72, 73, 74, 75, 76, 77, 96

Facility/Agency/Organization/Institution

01, 02, 03, 05, 20, 40, 42, 43, 44, 46, 50, 51, 53, 55, 57, 58, 59, 65, 66, 68, 69,
70, 73, 74, 75, 76, 78, 80, 88, 89, 90, 92, 93, 94, 95, 96, 98

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Appendix 3: Provider Type Matrix
Provider
Type

NPI required?

Taxonomy
required?

License/Certification
required?

Applicable Program(s)

Self-Enrollment
allowed? **

01







All



02







All



03







All



05







All



20







All



25







All



27







All



28







All



29







All



30







All



31







All



32







All





DEEOIC

33
34







DFEC



35







All



36







All



37







All



38







All



40







All







DFEC





All



43



All



44



All





All



41
42

46

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





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Provider
Type

NPI required?

Taxonomy
required?

License/Certification
required?

Applicable Program(s)

Self-Enrollment
allowed? **

47







DFEC

50







All



51

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OWCP-1168
(Revised 02/23)
Page 19

Provider
Type

NPI required?

Taxonomy
required?

License/Certification
required?

Applicable Program(s)

Self-Enrollment
allowed? **

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** If Self-Enrollment is not allowed for a certain provider type, please contact 1-844-493-1966.

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OWCP-1168
(Revised 02/23)
Page 20