OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

Provider Enrollment Form

IC 38462 under ICR 201606-1240-007 · OMB 1240-0021.

Documents and Forms
Document Name
Document Type
Form and Instruction
Form and Instruction
Form and Instruction
Information Collection (IC) Details

View Information Collection (IC)

Provider Enrollment Form
 
No Modified
 
Voluntary
 
20 CFR 10.801 20 CFR 725.705 20 CFR 30.701 20 CFR 725.704

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction OWCP-1168 Provider Enrollment Form OWCP-1168 Revised.pdf http://owcp.dol.acs-inc.com/portal/formsAndLinks.do Yes No Fillable Printable
Form and Instruction OWCP-1168 Web version screen shots Provider Enrollment For, Screen Shots Screen Shots of Billing Contractor's Web Portal.pdf http://owcp.dol.acs-inc.com/portal/formsAndLinks.do Yes Yes Fillable Fileable Signable

Health Health Care Services

DOL/GOVT-1(for FECA); DOL/ESA-6(for BLBA); AND DOL/ESA-49 (for EEOICPA)  67 FR 16826

31,979 0
   
Private Sector Businesses or other for-profits
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 31,979 0 0 0 0 31,979
Annual IC Time Burden (Hours) 4,252 0 0 0 0 4,252
Annual IC Cost Burden (Dollars) 16,629 0 0 0 0 16,629

Title Document Date Uploaded
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            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.