The Owcp 1168 form is a document used to apply for Workers' Compensation benefits. The form can be completed online or through the mail, and it is important to ensure that all information is accurate and complete. In order to qualify for Workers' Compensation benefits, you must have suffered an injury or illness while on the job. Completed applications can be submitted online or by mail. For more information, visit our website today.
Here is some specifics that will help you determine the time it will require to finish the owcp 1168 form.
Question | Answer |
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Form Name | Owcp 1168 Form |
Form Length | 28 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 7 min |
Other names |
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
OWCP has contracted to provide medical bill processing services for these four programs. As part of their benefit structure, these programs reimburse medical and
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
To assist claimants seeking medical services, OWCP has an
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 8300
London, KY
U.S. Department of Labor OWCP/DEEOIC
P. O. Box 8304
London, KY
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U.S. Department of Labor OWCP/DCMWC
P. O. Box 8302
London, KY
U.S. Department of Labor OWCP/DLHWC
P. O. Box 8313
London, KY
If you have any questions regarding this information, please contact us at:
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 federal 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.
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Provider Enrollment Form |
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U.S. Department of Labor |
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Office of Workers’ Compensation Programs |
OMB Number
Expires: 12/31/2023
1. Are you applying for a new enrollment or updating your record?
New Enrollment |
Update |
1a. If Update,
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 Select
(For
If you select “Other Provider” (96) or
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Program |
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DCMWC |
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5. |
Individual Information (If you enroll using SSN) |
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5a. |
Last Name |
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5c. Middle Name |
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5b. |
First Name |
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6. |
Organization Information |
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6a. |
Organization Name |
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(Legal Business Name) |
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6b. |
Organization Business Name |
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(Doing Business As) |
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7.National Provider Identifier (NPI)
8.Entity Type Select
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
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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
12. Physical Address
12a. Address Line 1
Address Line 2
Address Line 3
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12b. |
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12c.State/Province |
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12e. |
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13. Mailing Address |
Same as Physical Address |
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13a. Address Line 1 |
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Address Line 2 |
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Address Line 3 |
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13b. |
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13e. |
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PART C: TAXONOMY |
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14. Taxonomy a. |
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Code(s) |
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PART D: OWNERSHIP DETAILS
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15. |
Organization Owner |
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15a. |
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15b. FEIN |
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Organization Name |
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16. |
Individual Owner |
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16a. |
Last Name |
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17. |
Address |
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17a. Address Line 1 |
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Address Line 2 |
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Address Line 3 |
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17b. |
City/Town |
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17c. State/Province |
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17d. Zip Code |
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17e. |
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Additional Ownership Information |
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18. |
Organization Owner |
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18a. |
Organization Name |
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18b. FEIN |
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19. |
Individual Owner |
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19a. |
Last Name |
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19c. SSN |
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20. Address
20a. Address Line 1
Address Line 2
Address Line 3
20b. |
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20e. |
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20f. Country |
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PART E: LICENSE AND CERTIFICATION |
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21a. |
License/Certification Category |
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21b. Name |
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21c. |
License/Certification Type |
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21d. License/Certification Number |
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21e. Initial Issue Date |
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21f. Expiration Date |
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21g. Issued State |
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21h. Issuer Agency |
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21i. |
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Web Link |
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21j. |
License/Certification not required by State. |
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Please explain |
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Additional License/Certification |
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22a. |
License/Certification Category |
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22b. Name |
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22c. |
License/Certification Type |
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22d. License/Certification Number |
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22e. Initial Issue Date |
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22f. Expiration Date |
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22g. Issued State |
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22i. |
Web Link |
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(Revised 04/20) |
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Page 4 |
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PART F: IDENTIFIERS |
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23. Provider Identifier Information |
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23a. Identifier Type |
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Select |
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23b. Identifier Value |
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23c. Start Date |
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23d. End Date |
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24. Additional Provider identifier information |
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24a. Identifier Type |
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24b. Identifier Value |
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24c. Start Date |
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24d. End Date |
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PART G: EDI SUBMISSION METHOD
25. Mode of Submission. Check all applicable |
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Billing Agent/Clearinghouse |
Web Interactive |
FTP Secured Batch |
Web Batch |
None |
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PART H: EDI SUBMITTER DETAILS
26. Billing Agent/Clearinghouse/Submitter Information
26a. Billing Agent/Clearinghouse OWCP ID
26b. Start Date 26c. End Date
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Page 5 |
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 |
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Address Line 2 |
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Address Line 3 |
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28b. City/Town |
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28c. State/Province |
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28d. Zip Code |
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28e. County |
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28f. Country |
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29. Additional EDI Contact Information |
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29a. Contact Title |
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29b. Last Name |
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29c. First Name |
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29d. Phone Number |
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29e. Fax Number |
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29f. Email Address |
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30. Address |
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30a. Address Line 1 |
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Address Line 2 |
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Address Line 3 |
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30b. City/Town
30c. State/Province Select
30d. Zip Code
30e. County
30f. Country
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(Revised 04/20) |
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Page 6 |
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:
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
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.
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(Revised 04/20) |
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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
I have completed an ACH Vendor Payment/Electronic Fund Transfer (EFT) form.
Print Name and Title
Signature Date
Print, sign and mail or fax form to the following address:
Provider Enrollment
Department of Labor - OWCP
P. O. Box 8312
London, KY
Fax:
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(Revised 04/20) |
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Page 8 |