Department of labor provider enrollment form 2004-2025

1. Click ‘Get Form’ to open the department of labor provider enrollment form 2004 in the editor.
2. Begin by indicating whether you are applying for a new enrollment or updating your record. If updating, enter your Provider Number or EIN.
3. Fill in the earliest date you treated a participant in any OWCP program. This is crucial for establishing your eligibility.
4. Provide your practice information, including Practice Name, Address, City, State, and Zip Code. Ensure all details are accurate to avoid processing delays.
5. Select the type of practice (Individual, Facility, or Group) and complete the relevant sections based on your selection.
6. Enter your Tax ID (EIN or SSN) and Medicare Number if applicable. This information is essential for billing purposes.
7. Complete the License and Certification section if you are an M.D. or D.O., providing necessary details such as License Number and Specialty Codes.
8. Indicate if you have completed a form for Electronic Funds Transfer (EFT) and express interest in electronic billing if desired.
9. Finally, sign and date the form before submitting it to the appropriate program address provided at the end of the document.

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