Provider Enrollment Form

This ICR seeks approval under the PRA for revisions to the Provider Enrollment Form (Form OWCP-1168). The form requests profile information on providers that enroll in one or more of OWCP's benefit programs so its billing contractor can pay them for services rendered to beneficiaries using its automated bill processing system. In addition to the enrollment form information collection, the OWCP bill processing contractor currently collects electronic data interchange (EDI) information from the provider only if the provider chooses a data exchange submission method.

The latest form for Provider Enrollment Form expires 2023-12-31 and can be found here.