Provider Enrollment Form

OMB 1240-0021

OMB 1240-0021

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.

Latest Forms, Documents, and Supporting Material
Document
Name
Form and Instruction
Form and Instruction
Justification for No Material/Nonsubstantive Change
Justification for No Material/Nonsubstantive Change
Supplementary Document
Supplementary Document
Supplementary Document
Supplementary Document
Supporting Statement A
Supporting Statement A
Supplementary Document
Supplementary Document
Supplementary Document
Supplementary Document
Supplementary Document
Supplementary Document
Supplementary Document
Supplementary Document
Supplementary Document
Supplementary Document
All Historical Document Collections
No material or nonsubstantive change to a currently approved collection 2023-01-20
Approved without change
Extension without change of a currently approved collection 2020-09-23
Approved without change
No material or nonsubstantive change to a currently approved collection 2020-04-13
Approved with change
Revision of a currently approved collection 2020-02-14
Approved with change
Revision of a currently approved collection 2019-02-13
Approved without change
Revision of a currently approved collection 2018-05-31
Approved without change
No material or nonsubstantive change to a currently approved collection 2018-01-08
Approved without change
No material or nonsubstantive change to a currently approved collection 2017-06-01
Comment filed on proposed rule and continue
Revision of a currently approved collection 2017-01-10
Approved without change
No material or nonsubstantive change to a currently approved collection 2016-07-28
Approved without change
Revision of a currently approved collection 2016-01-29
Comment filed on proposed rule and continue
Revision of a currently approved collection 2015-11-18
Approved without change
Revision of a currently approved collection 2012-11-07
Approved without change
Extension without change of a currently approved collection 2010-03-12

© 2023 OMB.report | Privacy Policy