Provider Enrollment Form

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form OWCP-1168 Provider Enrollment Form	Form and Instruction	Modified	Available
WCPO-2026-0133-DRAFT-0002.pdf	Public Comments	Uploaded 2026-06-26	Available
Supporting Statement 1240-0021 OWCP 1168_2026_20260626.docx	Supporting Statement A	Uploaded 2026-06-26	Available
1168 Cover letter_rev_11.17.2023.pdf	Supplementary Document	Uploaded 2023-11-22	Available
30-day FRN_1240-0021.pdf	Supplementary Document	Uploaded 2023-10-03	Available
60 day FRN 20230629.pdf	Supplementary Document	Uploaded 2023-09-27	Available
20 CFR 725.704 and 705 BLBA Supporting Reg.pdf	Supplementary Document	Uploaded 2012-11-05	Available
20 CFR 30.701 EEOICPA Supporting Reg.pdf	Supplementary Document	Uploaded 2012-11-05	Available
20 CFR 10.801 FECA - Supporting Reg.pdf	Supplementary Document	Uploaded 2012-11-05	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
38462	Provider Enrollment Form	Form and Instruction	Modified	Provider Enrollment Form

ICR Details

OMB Control No: 1240-0021	ICR Reference No: 202603-1240-002
Status: Received in OIRA	Previous ICR Reference No: 202309-1240-001
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Provider Enrollment Form
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 06/29/2026

table that charts list comparision

	Requested	Previously Approved
Expiration Date	36 Months From Approved	12/31/2026
Responses	18,417	23,318
Time Burden (Hours)	8,902	9,716
Cost Burden (Dollars)	0	816

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Abstract: The information provided on this form will be used by all OWCP programs to identify the providers of medical and vocational rehabilitation services, and to direct payments to these providers accurately and in a timely manner.

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Authorizing Statute(s): US Code: 5 USC 8101 Name of Law: The Federal Employees' Compensation Act (FECA)
   US Code: 42 USC 7384 Name of Law: The Energy Employees Occupational Illness Compensation Program Act of 2000 (EEOICPA)
   US Code: 30 USC 901 Name of Law: The Black Lung Benefits Act (BLBA)
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	91 FR 13069	03/18/2026
30-day Notice:	Federal Register Citation:	Citation Date:
	91 FR 39123	06/29/2026
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
Provider Enrollment Form	OWCP-1168	Provider Enrollment Form

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ICR Summary of Burden

table that charts list of burden

	Total Request	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	18,417	23,318	0	-4,901	0	0
Annual Time Burden (Hours)	8,902	9,716	0	-814	0	0
Annual Cost Burden (Dollars)	0	816	0	-816	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: The changes to form 1168 include changes to the fields and instructions. OWCP is mandating electronic enrollment and only allowing paper/fax submissions in certain extenuating circumstances that make electronic submission impossible. The bill processing system currently allows electronic enrollments and is being enhanced to accommodate the revisions.

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Annual Cost to Federal Government: $301,855

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 06/29/2026

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