OMB control number
Provider Enrollment Form
OMB 1240-0021 ยท DOL/OWCP.
OMB 1240-0021
OWCP currently requires all service providers to submit all required medical licenses and the additional attestation language requires providers to further affirm that that they possess all appropriate state, county, locality, or jurisdictional business licenses to provide services to OWCP claimants. Together, these changes will reduce the complexity of the form for the form filler, without adding any additional fillable fields.
The latest form for Provider Enrollment Form expires 2026-12-31 and is listed under ICR 202309-1240-001.
Latest Forms, Documents, and Supporting Material
| Document | Type |
|---|---|
 Form OWCP-1168 Provider Enrollment Form | Form and Instruction |
| WCPO-2026-0133-DRAFT-0002.pdf | Public Comments |
 Supporting Statement 1240-0021 OWCP 1168_2026_20260626.docx | Supporting Statement A |
| 1168 Cover letter_rev_11.17.2023.pdf | Supplementary Document |
| 30-day FRN_1240-0021.pdf | Supplementary Document |
| 60 day FRN 20230629.pdf | Supplementary Document |
| 20 CFR 725.704 and 705 BLBA Supporting Reg.pdf | Supplementary Document |
| 20 CFR 30.701 EEOICPA Supporting Reg.pdf | Supplementary Document |
| 20 CFR 10.801 FECA - Supporting Reg.pdf | Supplementary Document |
 Provider Enrollment Form |
Form and Instruction |