Owcp 1168 Form PDF Details

Healthcare providers expressing interest in delivering medical services to beneficiaries of the U.S. Department of Labor's Office of Workers' Compensation Programs (OWCP) encounter a critical step in the form of the OWCP-1168 form. This form serves as an enrollment gateway for providers aiming to participate in the four significant disability compensation programs overseen by the OWCP. These programs, namely 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), offer benefits to workers or their dependents suffering from work-related injuries or occupational diseases. By completing the OWCP-1168 form, providers can become eligible to receive reimbursements for medical services rendered to claimants under these programs, contingent upon the maintenance of proper licensure and adherence to federal payment mandates such as the Debt Collection Improvement Act of 1996, which necessitates Electronic Funds Transfer (EFT) for federal payments. With detailed instructions for completing the form, specifics on EFT enrollment, and the need for current licensure information, the OWCP makes it clear that meticulous compliance is essential for the continued participation of providers in these crucial compensation programs. The form necessitates providers enrolling for each office location they operate, with the possibility of registering in one or more compensation programs, further detailed through guidelines on an inclusive provider listing online, thereby streamlining the process for claimants seeking medical services.

Form NameOwcp 1168 Form
Form Length28 pages
Fillable fields0
Avg. time to fill out7 min
Other names

Form Preview Example

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 8300

London, KY 40742-8300

U.S. Department of Labor OWCP/DEEOIC

P. O. Box 8304

London, KY 40742-8304

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U.S. Department of Labor OWCP/DCMWC

P. O. Box 8302

London, KY 40742-8302

U.S. Department of Labor OWCP/DLHWC

P. O. Box 8313

London, KY 40742-8313

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 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




U.S. Department of Labor





Office of Workers’ Compensation Programs

OMB Number 1240-0021

Expires: 12/31/2023

1. Are you applying for a new enrollment or updating your record?

New Enrollment




1a. If Update, Re-Enrollment or Re-Validation,

Enter Provider ID or Federal Employer Identification Number (FEIN)


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 multi-specialty group provider, select primary provider type)

If you select “Other Provider” (96) or Non-Medical Vendor (53) 3a. Please explain













































Individual Information (If you enroll using SSN)


























Last Name







5c. Middle Name



















First Name







5d. SSN





















Organization Information






























Organization Name














(Legal Business Name)










Organization Business Name







6c. FEIN





(Doing Business As)


























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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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

































12d. Zip Code
























































12f. Country




































13. Mailing Address

Same as Physical Address












13a. Address Line 1






































Address Line 2







































Address Line 3












































































































13c. State/Province


13d. Zip Code





















































13f. Country


































































































14. Taxonomy a.

















































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Organization Owner





































15b. FEIN







Organization Name








































Individual Owner



















































Last Name





16b. First Name




16c. SSN




































































17a. Address Line 1










































Address Line 2










































Address Line 3


























































































17c. State/Province



17d. Zip Code



















































17f. Country




































Additional Ownership Information


































Organization Owner






























Organization Name








18b. FEIN





























Individual Owner







































Last Name


19b. First Name



19c. SSN



























20. Address

20a. Address Line 1

Address Line 2

Address Line 3





20c. State/Province



20d. Zip Code














































20f. Country


















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License/Certification Category





21b. Name























































License/Certification Type






21d. License/Certification Number































































































21e. Initial Issue Date





21f. Expiration Date
















































21g. Issued State



21h. Issuer Agency




















































Web Link













































License/Certification not required by State.























Please explain











































Additional License/Certification
























































License/Certification Category





22b. Name













































License/Certification Type





22d. License/Certification Number






































22e. Initial Issue Date



22f. Expiration Date




































22g. Issued State



22h. Issuer Agency













































Web Link







































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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
































25. Mode of Submission. Check all applicable



Billing Agent/Clearinghouse

Web Interactive

FTP Secured Batch

Web Batch




26. Billing Agent/Clearinghouse/Submitter Information

26a. Billing Agent/Clearinghouse OWCP ID

26b. Start Date 26c. End Date

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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 Select

30d. Zip Code

30e. County

30f. Country

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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.


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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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

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 40742-8312

Fax: 888-444-5335

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How to Edit Owcp 1168 Form Online for Free

The Owcp 1168 Form completing process is easy. Our software lets you use any PDF file.

Step 1: Press the orange "Get Form Now" button on this webpage.

Step 2: You're now on the form editing page. You can edit, add text, highlight selected words or phrases, place crosses or checks, and include images.

Prepare the Owcp 1168 Form PDF and enter the information for each and every section:

Owcp 1168 Form fields to fill in

The system will need you to fill out the If you select Other Provider or, a Please explain, Program, DFEC, DCMWC, DEEOIC, DLHWC, Individual Information If you, c Middle Name, d SSN, c FEIN, a Last Name, b First Name, Organization Information, and a Organization Name segment.

Filling in Owcp 1168 Form step 2

Remember to provide the important information from the a If Other please explain, Email Address, I do not wish to be included in an, a Reason, Previous editions unusable, and OWCP Revised Page field.

Finishing Owcp 1168 Form stage 3

You'll have to spell out the rights and obligations of every party in box Location Contact Information, a Business Name, b Contact Last Name, c Contact First Name, d Phone Number, e Fax Number, f Email Address, Physical Address, a Address Line, Address Line, Address Line, b CityTown, cStateProvince, d Zip Code, and e C ounty.

Filling in Owcp 1168 Form stage 4

Finalize by looking at the following fields and writing the proper particulars: a Address Line, Address Line, Address Line, b CityTown, c StateProvince, d Zip Code, e County, f Country, Taxonomy Codes, PART C TAXONOMY, Previous editions unusable, and OWCP Revised Page.

Finishing Owcp 1168 Form step 5

Step 3: As soon as you choose the Done button, your finished form can be easily exported to any kind of your gadgets or to electronic mail given by you.

Step 4: Be sure to avoid possible complications by making minimally 2 copies of your form.

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