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Federal forms, ICRs, and supporting documents

Information Collection Request

Provider Enrollment Form

ICR 201606-1240-007 · OMB 1240-0021 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
Form OWCP-1168 Provider Enrollment Form Form and Instruction Modified Repair queued
NOTICE TO REVIEWER 1240-0021.docx Justification for No Material/Nonsubstantive Change Uploaded 2016-07-05 Repair queued
SS 1240-0021 (OWCP-1168).docx Supporting Statement A Uploaded 2016-01-22 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
IC IDCollectionTypeStatusForm
38462 Provider Enrollment Form Form and Instruction Modified
ICR Details
1240-0021 201606-1240-007
Historical Active 201601-1240-007
DOL/OWCP
Provider Enrollment Form
No material or nonsubstantive change to a currently approved collection   No
Regular
Approved without change 08/04/2016
Retrieve Notice of Action (NOA) 07/28/2016
  Inventory as of this Action Requested Previously Approved
05/31/2019 05/31/2019 05/31/2019
31,979 0 31,979
4,252 0 4,252
16,629 0 16,629
Form OWCP-1168 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.
US Code: 30 USC 901 Name of Law: The Black Lung Benefits Act (BLBA)
   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)
  
None
Not associated with rulemaking
  80 FR 38749 07/07/2015
81 FR 9513 02/25/2016
No
1
IC Title Form No. Form Name
Provider Enrollment Form OWCP-1168, OWCP-1168 Web version screen shots Provider Enrollment Form ,   Provider Enrollment For, Screen Shots
  Total Approved 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 31,979 31,979 0 0 0 0
Annual Time Burden (Hours) 4,252 4,252 0 0 0 0
Annual Cost Burden (Dollars) 16,629 16,629 0 0 0 0
No
No
There has been a decrease in the number of respondents seeking to provide medical or vocational services to beneficiaries. Accordingly, the burden hours decreased from 7,174 to 4,252, an adjustment of 2,922 hours and the operational and maintenance costs decreased from $25,888 to $16,629, an adjustment of $9,259. While not affecting burden estimates, we updated the form OWCP-1168 including: provider letter, privacy act statement, several items on the form and instructions.
$925,685
No
No
No
No
No
Uncollected
Yoon Ferguson 202 693-0701 [email protected]
  No
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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
07/28/2016