OMB control number

Provider Enrollment Form

OMB 1240-0021 · 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 can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Form OWCP-1168 Provider Enrollment Form Form and Instruction
30-day FRN_1240-0021.pdf Supplementary Document
60 day FRN 20230629.pdf Supplementary Document
Supporting Statement 1240-0021 OWCP 1168 2023 _20230927_FINAL.docx Supporting Statement A
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

All Historical Document Collections

202309-1240-001 Approved with change	Revision of a currently approved collection	2023-10-03
202301-1240-005 Approved without change	No material or nonsubstantive change to a currently approved collection	2023-01-20
202007-1240-002 Approved without change	Extension without change of a currently approved collection	2020-09-23
202004-1240-004 Approved without change	No material or nonsubstantive change to a currently approved collection	2020-04-13
202002-1240-001 Approved with change	Revision of a currently approved collection	2020-02-14
201901-1240-002 Approved with change	Revision of a currently approved collection	2019-02-13
201805-1240-004 Approved without change	Revision of a currently approved collection	2018-05-31
201712-1240-002 Approved without change	No material or nonsubstantive change to a currently approved collection	2018-01-08
201705-1240-002 Approved without change	No material or nonsubstantive change to a currently approved collection	2017-06-01
201612-1240-004 Comment filed on proposed rule and continue	Revision of a currently approved collection	2017-01-10
201606-1240-007 Approved without change	No material or nonsubstantive change to a currently approved collection	2016-07-28
201601-1240-007 Approved without change	Revision of a currently approved collection	2016-01-29
201507-1240-001 Comment filed on proposed rule and continue	Revision of a currently approved collection	2015-11-18
201207-1240-004 Approved without change	Revision of a currently approved collection	2012-11-07
201003-1240-021 Approved without change	Extension without change of a currently approved collection	2010-03-12