Fillable Thank you for your interest in participating as (Department of Labor)

Fill Online, Printable, Fillable, Blank Thank you for your interest in participating as (Department of Labor) Form

Use Fill to complete blank online DEPARTMENT OF LABOR (DC) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Thank you for your interest in participating as (Department of Labor)

On average this form takes 41 minutes to complete

The Thank you for your interest in participating as (Department of Labor) form is 20 pages long and contains:

  • 0 signatures
  • 13 check-boxes
  • 158 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Department of Labor

BROWSE DEPARTMENT OF LABOR (DC) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Dear Provider:
Thank you for your interest in participating as a medical services provider for the four programs administered by the U.S.
Department of Labor's Office of Workers' Compensation Programs (OWCP). The OWCP administers four major disability
compensation programs which provide benefits to certain workers or their dependents who experience work-related injury
or occupational disease. These programs include the Division of Federal Employees’ Compensation (DFEC), the Division
of Energy Employees Occupational Illness Compensation (DEEOIC), the Division of Coal Mine Workers’ Compensation
(DCMWC), and the Division of Longshore and Harbor Workers’ Compensation (DLHWC).
OWCP has contracted to provide medical bill processing services for these four programs. As part of their benefit structure,
these programs reimburse medical and non-medical providers for services rendered for the care and treatment of a
claimant’s compensable condition.
OWCP can only process bills from providers who have enrolled. To enroll, complete the enclosed provider enrollment form
to be assigned a provider identification number. Instructions for completing the enrollment form and a list of provider types
are enclosed. Any Provider Enrollment Form that is received with missing or incomplete information will be returned to the
submitter for correction and/or completion.
The Debt Collection Improvement Act of 1996 requires that payments made by the Federal Government be sent by
electronic funds transfer (EFT). EFT payments are mandatory because it simplifies the process, reduces the incidents of
billing error, and allows for expedited handling. An enrollment form for EFT is enclosed. A remittance advice listing all bills
paid on each EFT transaction will be sent to your mailing address. Please see notice on page 2.
You must submit current licensure information with your enrollment application. Moreover, each provider must
maintain appropriate current licensure in order to receive payments under OWCP's programs.
Group practices are responsible for monitoring the licensure of each servicing provider in the practice. Where
large group practices have providers in the group who are not providing medical services to our program on a
regular basis, the group practice is responsible for monitoring the licensure of each provider who practices in the
entire group.
Providers are required to enroll for each office location. Servicing providers under a group practice are not required to enroll
separately.
You may register as a participant in any one or more of the following four OWCP compensation programs – DFEC, DEEOIC,
DCMWC, and DLHWC. Please send the completed package(s)) at the address listed on the signature page (page 8) in the
Form OWCP-1168.
To assist claimants seeking medical services, OWCP has an on-line listing of providers, by program that is searchable by:
specialty, name, city, state, and zip code. Customers will be advised that a provider listing is not an endorsement, referral,
or an agreement to reimburse for medical services rendered by the Department of Labor or OWCP. Nor does it guarantee
that a medical provider will be reimbursed by OWCP for specific medical services or that a medical provider will agree to
provide medical services to a particular claimant.
You will be notified by mail once your enrollment package has been processed. Once you have received your OWCP
provider number, you may submit bills to the appropriate program at the following address(s):
U.S. Department of Labor OWCP/DFEC
P. O. Box 34450
San Antonio, TX 78265
U.S. Department of Labor OWCP/DEEOIC
P. O. Box 34930
San Antonio, TX 78265
Previous editions unusable
OWCP-1168
(Revised 04/2020)
Page 1
U.S. Department of Labor OWCP/DCMWC
P. O. Box 34297
San Antonio, TX 78265
U.S. Department of Labor OWCP/DLHWC
P. O. Box 34927
San Antonio, TX 78265
If you have any questions regarding this information, please contact us at:
1-844-493-1966
Our business hours are Monday through Friday from 8:00 a.m. to 8:00 p.m., Eastern Time.
NOTICE: Please be aware that the information being requested on Department of Treasury SF 3881- Payment Information
Form ACH Vendor Payment System - is required as part of the Department of Treasury Regulation 31 C.F.R. Part 208. This
f
ederal regulation, in part, requires that all agencies issuing federal payment do so via Electronic Fund Transfer (EFT). This
includes but is not limited to the requirement of requesting a bank signature. Failure to include this information at the time
the provider enrollment and ACH Payment Information forms are submitted will result in the return of these documents to
the provider.
NOTICE: Continued participation as a medical provider under the four DOL programs above can be contingent on
your maintaining good standing as a medical provider under other federal health benefit programs such as
Medicare. Exclusion as a medical provider in those circumstances operates as an automatic exclusion under the
DFEC, DEEOIC and DLHWC Programs administered by OWCP. (See 20 C.F.R. §§ 10.815, 30.715, and 702.431). You
may also be subject to the federal government’s suspension and debarment provisions. (See 48 C.F.R. Subpart
9.4 and 2 C.F.R. Part 180).
Previous editions unusable
OWCP-1168
(Revised 04/2020)
Page 2
Provider Enrollment Form U.S. Department of Labor
Office of Workers’ Compensation Programs
OMB Number 1240-0021
Expires: 09/30/2020
1. Are you applying for a new enrollment or updating your record?
New Enrollment Re-Enrollment
Re-Validation Update
1a. If Update, Re-Enrollment or Re-Validation,
Enter Provider ID or Federal Employer Identification Number (FEIN)
PART A: BASIC INFORMATION (Required)
2. Enrollment Type
Individual
Group Practice (Please see Page 9
for
completion of group practice enrollment)
Facility/Agency/Organization/Institution
3.
Provider Type
(For multi-specialty group provider, select primary provider type)
If you select “Other Provider” (96) or Non-Medical Vendor (53)
3a.
Please explain
4. Program
DFEC DCMWC DEEOIC DLHWC
5. Individual Information (If you enroll using SSN)
5a. Last Name
5b. First Name
5c. Middle Name
5d. SSN
6. Organization Information
6a. Organization Name
(Legal Business Name)
6b. Organization Business Name
(Doing Business As)
6c. FEIN
7. National Provider Identifier (NPI)
8. Entity Type
8a. If Other, please explain
9. Email Address
10. I do not wish to be included in an online searchable list of OWCP providers.
10a. Reason
Previous editions unusable
OWCP-1168
(Revised 04/2020)
Page 1
Print
Reset
Select
Reset
Select
PART B: LOCATION (Required)
11. Location Contact Information
11a. Business Name
11b. Contact Last Name
11c. Contact First Name
11d. Phone Number
11e.
Fax Number
11f. Email Address
12a. Address Line 1
Address Line 2
Address Line 3
12b. City/Town
12c.State/Province 12d. Zip Code
12. Physical Address
12e. C ounty
12f. Country
13. Mailing Address Same as Physical Address
13a. Address Line 1
Address Line 2
Address Line 3
13b. City/Town
13c. State/Province 13d. Zip Code
13e. County
13f. Country
PART C: TAXONOMY
14. Taxonomy
a.
c.
b.
d.
e.
Code(s)
Previous editions unusable
OWCP-1168
(Revised 04/2020)
Page 2
Select
Select
PART D: OWNERSHIP DETAILS
15. Organization Owner
15a. Organization Name 15b. FEIN
16. Individual Owner
16a. Last Name 16b. First Name 16c. SSN
17. Address
17a. Address Line 1
Address Line 2
Address Line 3
17b. City/Town 17c. State/Province 17d. Zip Code
17e. County 17f. Country
Additional Ownership Information
18. Organization Owner
18a. Organization Name 18b. FEIN
19. Individual Owner
19a. Last Name 19b. First Name 19c. SSN
20. Address
20a. Address Line 1
Address Line 2
Address Line 3
20b. City/Town 20c. State/Province 20d. Zip Code
20e. County 20f. Country
Previous editions unusable
OWCP-1168
(Revised 04/2020)
Page 3
Reset
Reset
Select
PART E: LICENSE AND CERTIFICATION
21a. License/Certification Category 21b. Name
21c. License/Certification Type
21d. License/Certification Number
21e. Initial Issue Date 21f. Expiration Date
21g. Issued State 21h. Issuer Agency
21i. Web Link
21
j. License/Certification not required by State.
21k. Please explain
Additional License/Certification
22a. License/Certification Category
22b. Name
22c. License/Certification Type
22d. License/Certification Number
22e. Initial Issue Date 22f. Expiration Date
22g. Issued State 22h. Issuer Agency
22i. Web Link
Previous editions unusable
OWCP-1168
(Revised 04/2020)
Page 4
Select
Select
Select
Select
PART F: IDENTIFIERS
23. Provider Identifier Information
23a. Identifier Type
23b. Identifier Value
23c. Start Date 23d. End Date
24. Additional Provider identifier information
24a. Identifier Type
24b. Identifier Value
24c. Start Date 24d. End Date
PART G: EDI SUBMISSION METHOD
25. Mode of Submission. Check all applicable
Billing Agent/Clearinghouse
FTP Secured Batch
Web Interactive
Web Batch None
PART H: EDI SUBMITTER DETAILS
26.
Billing Agent/Clearinghouse/Submitter Information
26a. Billing Agent/Clearinghouse OWCP ID
26b. Start Date 26c. End Date
Previous editions unusable
OWCP-1168
(Revised 04/2020)
Page 5
Select
Select
PART I: EDI CONTACT DETAILS
27. EDI Contact Information
27a. Contact Title
27b. Last Name 27c. First Name
27d. Phone Number 27e. Fax Number
27f. Email Address
28. Address
28a. Address Line 1
Address Line 2
Address Line 3
28b. City/Town 28c. State/Province 28d. Zip Code
28e. County 28f. Country
29. Additional EDI Contact Information
29a. Contact Title
29b. Last Name 29c. First Name
29d. Phone Number 29e. Fax Number
29f. Email Address
30. Address
30a. Address Line 1
Address Line 2
Address Line 3
30b. City/Town 30c. State/Province 30d. Zip Code
30e. County 30f. Country
Previous editions unusable
OWCP-1168
(Revised 04/2020)
Page 6
Select
Select
Privacy Act Statement
Collection of this information by OWCP is necessary for its administration of the Federal Employees’ Compensation Act, the
Black Lung Benefits Act, the Longshore and Harbor Workers’ Compensation Act and the Energy Employees Occupational
Illness Compensation Program Act, and is authorized under 20 CFR 10.800, 20 CFR 30.700, 20 CFR 702.145, 20 CFR
725.714 and 33 USC 918(b). The information provided will be used to ensure accurate payment of medical and vocational
rehabilitation provider bills and is protected by the Privacy Act of 1974, as amended (5 USC 552a) in accordance with the
following systems of records: DOL/GOVT-1, DOL/OWCP-4 DOL/OWCP-9 and DOL/OWCP-11, published in the Federal
Register, Vol. 81, page 25766, April 29, 2016, or as updated and republished. Completion and submission of this form is
voluntary; however, failure to provide the information (including SSN or FEIN) will result in substantially delayed payment
of bills. This information will be furnished to OWCP and its data processing contractors and may also be disclosed to
other federal and state agencies in connection with the administration of other programs, to the Department of Justice for
litigation purposes, and to medical and other provider review boards. Additional disclosures may be made through the routine
uses for information contained in the referenced systems of records.
Public Burden Statement
Under the Paperwork Reduction Act., persons are not required to respond to a collection of information unless such
collection displays a valid OMB control number. We estimate that it will take an average of 30 minutes to complete this
information collection, including time for reviewing the instructions, searching existing data sources, gathering and
maintaining the data needed, and completing and reviewing the information. If you have any comments regarding these
estimates or any other aspect of this collection including suggestions for reducing this burden, send them to the U.S.
Department of Labor, Office of Workers' Compensation Programs, Room S-3524, 200 Constitution Avenue, N.W.,
Washington, D.C. 20210. DO NOT SEND THE COMPLETED FORM TO THE ABOVE ADDRESS.
Notice
If you have a substantially limiting physical or mental impairment, Federal disability nondiscrimination law gives you the right to
receive help from OWCP in the form of communication assistance, accommodation and modification to aid you in the claims
process. For example, we will provide you with copies of documents in alternate formats, communication services such as
sign language interpretation, or other kinds of adjustments or changes to account for the limitations of your disability. Please
contact our office or the claims examiner to ask about this assistance.
Disclosure Statement
Within ten years of the date of this statement have you or any individual listed on this application had an action related to fraud
or abuse in a government program taken against him or her resulting in (1) a felony or misdemeanor conviction; (2) a liability
finding in civil proceedings; or (3) a settlement entered in lieu of conviction? Yes No
If Yes, provide details including type of action, Agency undertaking adverse action and date of action.
Required for DFEC providers
For Provider Type “Medical Supplies/Durable Medical Equipment (DME) / Prosthetics / Orthotics” (75) only:
Are you an accredited DMEPOS supplier enrolled with Medicare? Yes No
If Yes, provide the phone number that you used in your Medicare DMEPOS enrollment.
Previous editions unusable
OWCP-1168
(Revised 04/2020)
Page 7
Confirm and Sign
I, the undersigned, certify to the following: I have read the contents of this application, and the information contained herein is
true, correct, and complete. I authorize the OWCP to verify the information contained herein. I agree to notify the OWCP of any
change in ownership, practice location and/or Final Adverse Action involving fraud or abuse within 30 days of the reportable event.
In addition, I agree to notify the OWCP of any other changes to the information in this form within 90 days of the effective date of
change.
I also certify that I am not currently sanctioned, suspended, debarred or excluded by any Federal or State Health Care Program,
(e.g., Medicare, Medicaid, or any other Federal program), or otherwise prohibited from providing services to Medicare, Medicaid,
or other Federal program beneficiaries nor are any owners, officers, or managing employees of the practice listed in this
application.
I understand that any deliberate omission, misrepresentation, or falsification of any information contained in this application or
contained in any communication supplying information to the Department of Labor, Office of Workers’ Compensation Program
(OWCP), or any deliberate alteration of any text on this application form, may be punished by criminal, civil, or administrative
penalties including, but not limited to, the denial or revocation of OWCP billing privileges, civil damages, and/or imprisonment.
I agree to abide by the OWCP regulations and program instructions that apply to me or to the organization listed in Section 3A of
this enrollment form. I understand that payment of a claim by OWCP is conditioned upon the claim and the underlying transaction
complying with state and federal laws (including, but not limited to, the Federal anti-kickback statute) and OWCP regulations, and
program instructions.
I have completed an ACH Vendor Payment/Electronic Fund Transfer (EFT) form.
Print Name and Title
Date
Signature
Print, sign and mail or fax form to the following address:
Provider
Enrollment
Department of Labor - OWCP
P. O. Box 34690
San Antonio, TX 78265
Fax: 888-444-5335
Previous editions unusable
OWCP-1168
(Revised 04/2020)
Page 8
Addendum 1: Individual Providers Information for Group Practice Enrollment
(Part A)
Fill in this addendum to add, update or remove servicing providers for Group Practice as applicable.
• Reviewer will validate NPI for all servicing providers.
• Reviewer will also validate license and certificate for 9 or less servicing providers. For more than 9 providers, group is
responsible for validating license and certificate.
1.
2. Individual Information (Applicable if enrolling using SSN)
Add
2c. Middle Name
2a. Last Name
Update
Remove
2d. SSN
2b. First Name
3. Organization Information (Applicable if enrolling using FEIN)
3a. Organization Name
3b. Organization Business Name
3c. FEIN
4. Provider Type 5. NPI
6. Taxonomy
a. b. c. d. e.
7. License/Certification Information
ense/
License/Certification Type
License/
Certification
Number
Issued
State
Initial Issue
Date
Expiration
Date
Additional Addendum Information
1.
Add
Update
Remove
2. Individual Information (Applicable if enrolling using SSN)
2a. Last Name 2c. Middle Name
2b. First Name
2d. SSN
3. Organization Information (Applicable if enrolling using FEIN)
3a. Organization Name
3b. Organization Business Name
3c. FEIN
4. Provider Type
5. NPI
6. Taxonomy
a. b. c. d. e.
7. License/Certification Information
License/
Certification
Category
License/Certification Type
License/
Certification
Number
Issued
State
Initial Issue
Date
Expiration
Date
Previous editions unusable
OWCP-1168
(Revised 04/2020)
Page 9
License/
Certification
Category
Reset
Select
Select
Select
Select
Select
Reset
Select
Select
Select
Select
Select
Addendum 2: Taxonomy Information (Part C)
Type or print additional Taxonomy information as applicable.
Use additional sheet(s) as required.
Taxonomy
Previous editions unusable
OWCP-1168
(Revised 04/2020)
Page 10
Addendum 3: License and Certification (Part E)
Type or print additional license and certification information as applicable.
Use additional sheet(s) as required
1. License/Certification Category
2. Name
3. License/Certification Type 4
. License/Certification Number
5. Initial Issue Date 6. Expiration Date
7. Issued State
8
. Issuer Agency
9. Web Link
1. License/Certification Category 2. Name
3. License/Certification Type 4
. License/Certification Number
5. Initial Issue Date 6. Expiration Date
7. Issued State
8
. Issuer Agency
9. Web Link
1. License/Certification Category 2. Name
3. License/Certification Type 4
. License/Certification Number
5. Initial Issue Date 6. Expiration Date
7. Issued State
8
. Issuer Agency
9. Web Link
Previous editions unusable
OWCP-1168
(Revised 04/2020)
Page 11
Select
Select
Select
Select
Select
Select
Addendum 4: Billing Agent/Clearinghouse Provider ID (Part H)
Type or print additional Billing Agent/Clearinghouse Provider IDs as applicable.
Use additional sheet(s) as required.
Billing Agent/Clearinghouse ID Start Date End Date
Previous editions unusable
OWCP-1168
(Revised 04/2020)
Page 12
Instructions
A brief description of each data element is listed below. Be sure to sign and date the form when you submit it.
Part A: Basic Information
1.
Indicate whether this form is being used for a New Enrollment, to Update an
existing ACTIVE enrollment record, for a Re-Enrollment (previously enrolled
provider was excluded, now has become re-eligible) or to Re-Validate currently
enrolled but EXPIRED enrollment record.
Required
1a.
If the form is being submitted to Update, Re-Enrollment or Re-Validate your
record, enter your Provider Number or Federal Employer Identification Number.
• For Re-Validation and Re-Enrollment, complete all applicable sections,
sign and send the form.
• For Update, complete ONLY changed sections, sign and send the form.
Required if Update, Re-
Enrollment or Re-Validate
option is selected in 1
2.
Select Enrollment Type:
Individual
• Any provider who is eligible to receive a Type I National Provider
Identifier (NPI) through the National Plan and Provider Enumeration
System (NPPES). Providers eligible to receive an NPI are those who
deliver medical or health services, as defined under Section 1861(s) of
the Social Security Act, 42 U.S.C. 1395x(s).
• Individuals providing only non-medical services, attendant care, or
personal care services, who do not need an NPI.
Group Practice
• One or more health care practitioners who practice their profession at a
common location (whether or not they share common facilities, common
supporting staff, or common equipment) and have formed a partnership
or corporation or are employees of a person, partnership or corporation,
or other entity owning or operating the health care facilities at which they
practice. These entities have a Type II National Provider Identifier (NPI)
from the National Plan and Provider Enumeration System (NPPES).
• Fill out the appropriate parts in Addendum 1 of the form for each
professional that will be providing services under the group Provider
Number (Name, Social Security number, Provider Type Code from list
Required
Refer to Appendix 2 for more
information
below, NPI, DEA Number, Taxonomy, License or Certificate Type,
License Number, Issue Date, Issue State and Expiration Date of current
license). Continue additional sheet(s) as needed.
Facility/Agency/Organization/Institution
• An Inpatient or Outpatient Hospital, a Skilled Nursing Facility, an
Intermediate Care Facility, a Clinic (RHC, FQHC, Hospital Based Clinic,
Urgent Care), a Psychiatric Facility, a Mental Institution, a Durable
Medical Equipment Supplier, a Free Standing Ambulatory Surgical
Center, a Long Term Care Facility, an Independent Clinical Laboratory, a
Free Standing Radiology, a Dialysis Center, a Pharmacy, a Partnership,
a Corporation, or any other entity that furnishes or arranges for the
furnishing of services for which payment is billed under the OWCP
programs. It does not include individual practitioners or groups of
practitioners. In addition, you must also be eligible to receive and
currently possess, a Type II National Provider Identifier, available
through the National Plan and Provider Enumeration System (NPPES).
• Any entity other than individual who does not deliver medical care or
health services and is thus ineligible for a National Provider Identifier
Previous editions unusable
OWCP-1168
(Revised 04/2020)
Page 13
(NPI) available through the National Plan and Provider Enumeration
System (NPPES). This provider type can include Fiscal Intermediaries,
Non-Emergency Transportation, etc.
3.
Type or print Provider Type
For Group Practice, type or print primary Provider Type.
Required
Refer to Appendix 1 for more
information
3a. Type or print explanation for Provider Type
Required if 53 or 96 is selected
in 3.
4.
Check the Program(s) in which you want to enroll as a provider. If mailing, please
mail the application to P.O. Box as indicated on Page 8 of the application or fax a
separate document.
Required
Refer to Appendix 3 for more
information
5. Type or print Individual information Required if enrolled using SSN
5a. Type or print provider’s Last Name Required
5b. Type or print provider’s First Name Required
5c. Type or print provider’s Middle Name
5d. Type or print SSN Required
6. Type or print Organization information Required if enrolled using FEIN
6a. Type or print Organization Name (i.e.) Legal Business Name Required
6b. Type or print Organization Business Name (i.e.) Doing Business As Required
6c. Type or print FEIN Required
7.
Type or print NPI
Refer to Appendix 3 for
requirements
8.
Type or print IRS W9 Entity Type. Select from following values:
• C Corporation
• S Corporation
• Individual/Sole Proprietor or single-member LLC
• LLC Filing as C Corporation
• LLC Filing as S Corporation
• LLC Filing as Partnership
• LLC Filing as Sole Proprietor
• Others
• Partnership
Required
8a. Type or print Reason Required if selected Others in 8
9. Type or print Email Address
Previous editions unusable
OWCP-1168
(Revised 04/2020)
Page 14
10.
Select this option if you do not wish to be included in the OWCP online
searchable program. However, selecting this option will not exclude your
information in a FOIA (Freedom Of Information Act) request.
10a. Type or print Explanation
Required if checkbox is selected
in 10
Part B: Location Information
Providers offering services at different location(s) are required to enroll
separately for each location. Servicing providers under a group practice are not
required to enroll separately.
11. Location Contact information Required
11a. Type or print location Business Name Required
11b. Type or print contact Last Name Required
11c. Type or print contact First Name Required
11d. Type or print Phone number Required
11e. Type or print Fax number
11f. Type or print Email Address
12. Type or print Physical Address
12a. Type or print street Address Line 1 Required
Type or print street Address Line 2
Type or print street Address Line 3
12b. Type or print City or Town Required
12c. Type or print State or Province Required for domestic address
12d. Type or print Zip (or postal) Code Required
12e. Type or print County
12f. Type or print Country Required for foreign address
13.
Select this option if the mailing address is same as the physical address.
Otherwise print or type Mailing Address
13a. Type or print street Address Line 1
Type or print street Address Line 2
Type or print street Address Line 3
13b. Type or print City or Town
13c. Type or print State or Province
Previous editions unusable
OWCP-1168
(Revised 04/2020)
Page 15
13d. Type or print Zip (or postal) Code
13e. Type or print County
13f. Type or print Country
Part C: Taxonomy
14.
Type or print Taxonomy
Use Addendum 1 for taxonomy for servicing providers
Use Addendum 2 for additional taxonomy codes. Use additional sheet(s)
as required.
Refer to Appendix 3 for
requirements
Part D: Ownership Details
15. Type or print Organization Ownership information If enrolling using FEIN
15a. Type or print Organization Name
15b. Type or print FEIN
16. Type or print Individual Ownership information If enrolling using SSN
16a. Type or print individual Last Name
16b. Type or print individual First Name
16c. Type or print SSN
17. Type or print Ownership address
17a. Type or print street Address Line 1
Type or print street Address Line 2
Type or print street Address Line 3
17b. Type or print City or Town
Previous editions unusable
OWCP-1168
(Revised 04/2020)
Page 16
Part D is optional .
For DFEC and DEEOIC
providers, list any business
with more than a 5% interest
in or where involvement is at
an officer, director or agent of
the company
17c. Type or print State or Province For domestic address
17d. Type or print Zip (or postal) Code
17e. Type or print County
17f. Type or print Country
For foreign address only
Section 18 to 20 are for additional ownership information, use additional
sheets as required
18. Refer to instructions for Section 15
If additional sheets needed
19. Refer to instructions for Section 16
If additional sheets needed
20. Refer to instructions for Section 17
If additional sheets needed
Part E: License and Certification
• Please provide all license/certification required by your State to perform the
service under your Provider Type.
• If a license or certification is not required by the State, attach letter/
evidence from the State authority.
• OWCP will verify all your license/certification with your State's license
issuer agency before your enrollment can be approved.
• After your enrollment is approved, you are responsible to keep your
license/certification information up to date.
• Expired license/certification will cause the termination of the provider
status.
• If you have a renewed license/certification under a different number, please
make sure to enter it using the exactly same License/Certification Type.
21.
• Use Addendum 1 for license and certification information of servicing
providers for group practice enrollment.
• Refer to Addendum 3 to add additional license and certification information.
Use additional sheet(s), as required.
Refer to Appendix 3 for
requirements
21a.
Type or print license or certification category from following options:
• License
• certification
Required
21b. Type or print Name Required
21c. Type or print License or Certification Type Required
21d. Type or print License or Certification Number Required
Previous editions unusable
OWCP-1168
(Revised 04/2020)
Page 17
21e. Type or print License or Certification Initial Issue Date Required
21f. Type or print License or Certification Expiration Date Required
21g. Type or print License or Certification Issued State Required
21h. Type or print License or Certification Issuer Agency Required
21i. Type or print License or certification Web Link Required
21j. Select this option if License or Certification is not required by State
21k. Type or print Explanation Required if 25j. is selected
22.
Additional License and Certification information. Refer to instructions for section 21.
Use additional sheet(s) as required.
Part F: Identifiers
23. Identifier information
Medicare number is required for
hospitals (Provider type: 01, 02,
03)
23a.
Type or print Identifier Value from below list of values:
• DEA Number
• NPI
• Other Provider ID
• Previous Provider ID
• Provider Medicare Number
• United Mine Workers of America (UMWA) Number
Required
23b. Type or print Identifier Value Required
23c. Type or print Start Date Required
23d. Type or print End Date
24.
Additional Identifier information. Refer to instructions for section 23. Use
additional sheet(s) as required.
Part G: EDI Submission Method
25.
Select mode of Submission. Select all applicable options:
Billing
Agent/Clearinghouse
For providers who use a 3rd party to bill.
Web Interactive For entering (keying) bills directly in the System.
Previous editions unusable
OWCP-1168
(Revised 04/2020)
Page 18
FTP Secured Batch: For submitting files via an SFTP site.
Web Batch For upload/download of files in the system.
None For submissions through paper form ONLY.
• "Web Batch" method is often used by providers who submit their own
HIPAA batch transactions. It allows a maximum file size of 50 MB.
• Your EDI submission method is "FTP Secured Batch" if you submit
and retrieve batches at a secure web folder assigned to you by
OWCP. This method was designed with clearinghouses and billing
agents in mind. It allows a maximum file size of 100 MB.
• Don't select “None” if other submission method is selected. You can
always submit paper form in addition to EDI Submission.
Part H: EDI Submitter Details
26.
Billing Agent/Clearinghouse information
• Your Billing Agent/Clearinghouse must be enrolled with OWCP first.
• Please obtain the Billing Agent/Clearinghouse’s OWCP ID to complete
this section.
• If they are not yet enrolled, you can still complete your enrollment by
temporarily choosing not to use Billing Agent/Clearinghouse.
• You can add them later after they are enrolled with OWCP.
Refer to Addendum 4 for additional information. Use additional sheet(s) as
required.
Required if Billing
Agent/Clearinghouse selected in
Part G
26a. Type or print Billing Agent/Clearinghouse OWCP ID Required
26b. Type or print Start Date Required
26c. Type or print End Date
Part I: EDI Contact Details
27. EDI Contact information
Required if FTP Secured Batch
or Web Batch is selected in Part
G
27a. Type or print Contact Title Required
27b. Type or print contact last name Required
27c. Type or print contact First Name Required
27d. Type or print contact Phone number Required
Previous editions unusable
OWCP-1168
(Revised 04/2020)
Page 19
27e. Type or print contact Fax number
27f. Type or print contact Email Address
28. Type or print Contact Address
28a. Type or print street Address Line 1 Required
Type or print street Address Line 2
Type or print street Address Line 3
28b. Type or print City or Town Required
28c. Type or print State or Province Required for domestic address
28d. Type or print Zip (or postal) Code Required
28e. Type or print County
28f. Type or print Country Required for foreign address
29. Additional EDI Contact information. Refer to instructions for Section 27
30. Additional EDI Contact address. Refer to instructions for Section 28
Addendum 1: Servicing Providers Information
Required for enrollment type
Group Practice
1.
Select one option to add, update or remove a servicing provider:
• For New Enrollment, only Add action can be selected.
• Type or print all the information for New and Update Action.
• Type or print SSN or FEIN for Remove Action.
• Servicing providers can be enrolled using SSN (individual) or FEIN
(organization).
Required
2. Type or print Individual information Required if enrolled using SSN
2a. Type or print Last Name Required
2b. Type or print First Name Required
2c. Type or print Middle Name
2d. Type or print SSN Required
3. Type or print Organization information Required if enrolled using FEIN
3a. Type or print Organization Name Required
3b. Type or print Organization Business Name Required
3c. Type or print FEIN Required
Previous editions unusable
OWCP-1168
(Revised 04/2020)
Page 20
4. Type or print Provider Type
Required
Refer to Appendix 1 for more
information
5. Type or print NPI
Refer to Appendix 3 for
requirements
6. Type or print Taxonomy
Refer to Appendix 3 for
requirements
7. Type or print License/Certification information
Refer to Appendix 3 for
requirements
Type or print License or Certification Category from following options:
• License
• certification
Required
Type or print License or Certification Type Required
Type or print License or Certification Number Required
Type or print License or certification Issued State Required
Type or print License or certification Initial Issue Date Required
Type or print License or certification Expiration Date Required
Addendum 2: Taxonomy Refer to Part C instructions
Addendum 3: License and Certification Refer to Part E instructions
Addendum 4: Billing Agent/Clearinghouse Refer to Part H instructions
Supporting Documents
Required, please attach copy of
the applicable supporting
document(s)
1. ACH Form Required
2. Copy of License/Certification
Required if you provided
License/Certification information
in Part E
3. Other Supporting Document
4. Provider Enrollment Form Signature Page Required
5. State Approval Letter
If you selected License not
required by state option in Part E
Previous editions unusable
OWCP-1168
(Revised 04/2020)
Page 21
Appendix 1: Provider/Hospital Type Codes
01 General Hospital
63 Optician
02 Special Hospital/ Rehabilitation Facility
65 Home Health Agency
03 Psychiatric Hospital
66 Rural Health Clinic
05 Community Mental Health Center
67 DMA Consult Contractor
20 Pharmacy
68 Federally Qualified Health Center
25 Physician (MD) & Physician (DO)
69 Birthing Center
27 Podiatrist
70 Health Maintenance Organization or
28 Chiropractor
Preferred Health Plan
29 Physician Assistant
71 Physical Therapist
30 Advanced Registered Nurse Practitioner
72 Occupational Therapist
(ARNP)
73 Pulmonary Rehabilitation
31 Certified Registered Nurse Anesthetist
74 Outpatient Renal Dialysis Facility
(CRNA)
75 Medical Supplies/Durable Medical
32 Psychologist
Equipment (DME) /Prosthetics/Orthotics
33 Contract Medical Consultant
76 Case Management Agency
34 Licensed Midwife
77 Social Worker
35 Dentist
78 Blood Bank
36 Registered Nurse (RN)
80 Pay-to-Intermediary
37 Licensed Practical Nurse (LPN)
88 Ambulatory Surgery Center
38 Nursing Attendant
89 Federal Facility (VA Hospital)
40 Ambulance
90 Skilled Nursing Facility (SNF)-Medicare
41 Contract Nurse
Certified & Non-Medicare Certified
42 Air/Water Ambulance Company
92 Intermediate Care Facility (ICF)
43 Taxi
93 Rural Hospital Swing Bed
44 Public Transportation & Private
94 Boarding House
Transportation
95 Insurance Company (Third party Carriers)
46 Hospice
96 Other Provider
47 FOH-DMA Providers
97 Billing Agent
50 Independent Laboratory
98 Lien Holder
51 Portable X-Ray Company
52 Alternative Medicine (e.g., Massage
Therapist/Acupuncturist)
53 Non-Medical Vendor
55 Vocational Rehabilitation (Training, Tuition
and Schools)
56 Vocational Rehabilitation Counselor
57 Rehabilitation Maintenance
58 Assisted Re-employment
59 Relocation Expenses
60 Audiologist/Speech Pathologist
61 Second Opinion Contractor
62 Optometrist
Previous editions unusable
OWCP-1168
(Revised 04/2020)
Page 22
Appendix 2: Enrollment Type/Provider Type
Applicable provider types for each enrollment type are listed:
Enrollment Type Provider Type
Individual
25, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 40, 41, 42, 43, 44, 47, 50, 51,
52, 53, 55, 56, 57, 58, 59, 60, 61, 62, 63, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74,
75, 76, 77, 78, 80, 88, 95, 96, 98
Group Practice
25, 27, 28, 29, 30, 31, 32, 34, 35, 36, 37, 38, 43, 52, 60, 62, 63, 65, 66, 68, 69,
70, 71, 72, 73, 74, 75, 76, 77, 96
Facility/Agency/Organization/Institution
01, 02, 03, 05, 20, 40, 42, 43, 44, 46, 50, 51, 53, 55, 57, 58, 59, 65, 66, 68, 69,
70, 73, 74, 75, 76, 78, 80, 88, 89, 90, 92, 93, 94, 95, 96, 98
Previous editions unusable
OWCP-1168
(Revised 04/2020)
Page 23
Appendix 3: Provider Type Matrix
Provider
Type
NPI required?
Taxonomy
required?
License/Certification
required?
Applicable Program(s)
Self-Enrollment
allowed? **
01
All
02
All
03
All
05
All
20
All
25
All
27
All
28
All
29
All
30
All
31
All
32
All
33
DEEOIC
34
DFEC
35
All
36
All
37
All
38
All
40
All
41
DFEC
42
All
43
All
44
All
46
All
Previous editions unusable
OWCP-1168
(Revised 04/2020)
Page 24
Provider
Type
NPI required?
Taxonomy
required?
License/Certification
required?
Applicable Program(s)
Self-Enrollment
allowed? **
47
DFEC
50
All
51
All
52
All
53
All for DEEOIC
55
DFEC
56
DFEC
57
DFEC
58
DFEC
59 DFEC
60
All
61
All
62
All
63
All
65
All
66
All
67
DFEC
68
All
69
All
70
All
71
All
72
All
73
All
74
All
75
All
Previous editions unusable
OWCP-1168
(Revised 04/2020)
Page 25
Provider
Type
NPI required?
Taxonomy
required?
License/Certification
required?
Applicable Program(s)
Self-Enrollment
allowed? **
76
All
77
All
78
All
80
All
88
All
89
All
90
All
92
All
93
All
94
All
95
All
96
All
97 All
98 All
** If Self-Enrollment is not allowed for a certain provider type, please contact 1-844-493-1966.
Previous editions unusable
OWCP-1168
(Revised 04/2020)
Page 26
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Thank you for your interest in participating as (Department of Labor)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 5 October 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document