Form OWCP-3881 ACH Vendor Payment Enrollment Form

OMB Control No. 1240-0NEW

ACH VENDOR PAYMENT ENROLLMENT FORM

This form is used for Automated Clearing House (ACH) payments with an addendum record that contains payment-related information. Recipients of these payments should bring this information to the attention of their financial institution when presenting this form for completion. See page 2 for instructions in completing this form.

PAPERWORK REDUCTION ACT STATEMENT

The information being collected on this form is required under the provision of 31 U.S.C. 3322 and 31 CFR 210. This information will be used by the Treasury Department to transmit payment data by electronic means to vendor’s financial institution. Failure to provide the requested information may delay or prevent the receipt of payments through the Automated Clearinghouse Payment System.

MEDICAL PROVIDER INFORMATION
OWCP Provider ID
Name
Address
Contact Person Name				Telephone Number

AGENCY INFORMATION
Name: U.S. Department of Labor-Office of Workers’ Compensation Program
Address: Provider Enrollment
P. O. Box 8312, London, KY 40742-8312
Contact Person Name:	Telephone Number:

FINANCIAL INSTITUTION INFORMATION

Name

Street Address

City

State

Select

Zip Code

ACH Coordinator Name

Telephone Number

Nine-Digit Routing Transit Number

Depositor Account Title

Depositor Account Number

Type of Account Checking Savings

Signature and Title of Representative

Telephone Number

ACH Vendor Payment Enrollment Form Instructions (OWCP- 3881)

Public Burden Statement

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control number.  The valid OMB control number for this information collection is 1240-0NEW.  This collection of information is voluntary. We estimate that it will take an average of three minutes to complete this collection of information, including time for reviewing instructions, abstracting information from the patient’s records and entering the data onto the form.   This time is based on familiarity with standardized coding structures and prior use of this common form.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Office of Workers’ Compensation Programs, Department of Labor, Room S3522, 200 Constitution Avenue NW, Washington, DC 20210; and reference OMB control number 1240-0NEW, Washington, DC 20503.  DO NOT SEND THE COMPLETED FORM TO EITHER OF THIS OFFICE.

NOTICE

If you have a disability, federal law gives you the right to receive help from the OWCP in the form of communication assistance, accommodation(s) and/or modification(s) to aid you in the OWCP 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 of changes to accommodate your disability. Please contact our office or your OWCP claims staff to ask about this assistance.

OWCP- 3881 Department of Labor- OWCP Page 1

Expiration Date – XX/XX/XXXX