How to Complete a Provider Enrollment Application - Individual

How to Complete a Provider Enrollment Application - Individual.pptm

Provider Enrollment Form

How to Complete a Provider Enrollment Application - Individual

OMB: 1240-0021

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 1240-0021 can be found here:

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How to Complete a Provider Enrollment Application

INDIVIDUAL PROVIDER

OWCP Provider Enrollment

Application Tutorial

Completing an Enrollment Application

Provider Enrollment Form - U.S. Department of Labor

Completing an Enrollment Application

Completing an Enrollment Application
Provider Enrollment Form - U.S. Department of Labor

•Practice Information (Section 3)

•All practice types (Individual/Facility/Group), must complete this section of the application.

Completing an Enrollment Application
Provider Enrollment Form - U.S. Department of Labor
Providers MUST Select a Type of Practice

Completing an Enrollment Application
Provider Enrollment Form - U.S. Department of Labor

•If the provider checked “a” for individual practice, they must complete boxes 11a through 13c.

Completing an Enrollment Application
Provider Enrollment Form - U.S. Department of Labor

•Hospitals should complete 14a – 15d
•Individual practice providers should complete 15a – 15d

Completing an Enrollment Application
Provider Enrollment Form - U.S. Department of Labor

Completing an Enrollment Application
Provider Enrollment Form - U.S. Department of Labor
Disclosure Statement - New Addition to the Provider Enrollment Application

Submitting an Enrollment Application
Provider Enrollment Form - U.S. Department of Labor

For Federal Employees’ Compensation Act (FECA) Program

For Black Lung Program

For Energy Program

OWCP/FECA

P.O. Box 8300

London, KY

40742-8300

DCMWC/Black Lung

P.O. Box 8302

London, KY

40742-8302

DEEOIC

P.O. Box 8304

London, KY

40742-8304

If you have any questions regarding the completion of the form, please call Toll Free: 1-844-493-1966

If you have any questions regarding the completion of the form, please call Toll Free: 1-800-638-7202

If you have any questions regarding the completion of the form, please call Toll Free: 1-866-272-2682

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