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Federal forms, ICRs, and supporting documents

Information Collection Request

Provider Enrollment Form

ICR 201612-1240-004 · OMB 1240-0021 · Historical Inactive

Forms and Documents
DocumentTypeStatusAvailability
Form OWCP-1168 Provider Enrollment Form Form and Instruction Modified Available
NOTICE TO REVIEWER 1240-0021.docx Justification for No Material/Nonsubstantive Change Uploaded 2016-07-05 Available
ICR Supporting Statement 1240-0021 (OWCP-1168) for RuleMaking.docx Supporting Statement A Uploaded 2016-12-15 Available
20 CFR 725.704 and 705 BLBA Supporting Reg.pdf Supplementary Document Uploaded 2012-11-05 Repair queued
20 CFR 30.701 EEOICPA Supporting Reg.pdf Supplementary Document Uploaded 2012-11-05 Repair queued
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 201612-1240-004
Historical Inactive 201606-1240-007
DOL/OWCP
Provider Enrollment Form
Revision of a currently approved collection   No
Regular
Comment filed on proposed rule and continue 03/06/2017
Retrieve Notice of Action (NOA) 01/10/2017
In accordance with 5 CFR 1320, the information collection is not approved at this time. Prior to publication of the final rule, the agency should provide to OMB a summary of all comments received on the proposed information collection and identify any changes made in response to these comments.
  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
1240-AA11 Proposed rulemaking 82 FR 739 01/04/2017
  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
No
No
There has been an increase in the number of respondents seeking to provide medical or vocational services to beneficiaries. Accordingly, the burden hours increased from 4,252 to 4,955, an adjustment of 703 hours and the operational and maintenance costs increased from $16,629 to $18,629, an adjustment of $2,000. In addition, the proposed BLBA rule continues the current information collection requirements but would change where the regulatory authorities are codified. This ICR updates the regulatory citation for the BLBA program’s authority to collect the information.
$1,077,969
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.
01/10/2017