Information Collection

Provider Enrollment Form

IC 38462 under ICR 202004-1240-004 · OMB 1240-0021.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1240-0021 can be found here:

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Information Collection (IC) Details

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IC Title:	Provider Enrollment Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 20 CFR 10.801 20 CFR 725.704 20 CFR 30.701 20 CFR 725.705

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title: DOL/GOVT-1(for FECA); DOL/OWCP-2(for BLBA); AND DOL/OWCP-11 (for EEOICPA)	FR Citation: 81 FR 25766

Number of Respondents: 64,325	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	64,325	64,325
Annual IC Time Burden (Hours)	32,163	32,163
Annual IC Cost Burden (Dollars)	37,309	37,309

Documents for IC

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