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Department of labor provider enrollment form 2004-2026

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4.3 out of 5

46 votes

The document is a Provider Enrollment Form from the U.S. Department of Labor's Office of Workers’ Compensation Programs, used for enrolling or updating medical providers in various compensation programs. It collects essential information such as provider details, practice information, licensing, and billing preferences to ensure accurate payment for services rendered to participants.

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Click ‘Get Form’ to open the department of labor provider enrollment form 2004 in the editor.
Begin by indicating whether you are applying for a new enrollment or updating your record. If updating, enter your Provider Number or EIN.
Fill in the earliest date you treated a participant in any OWCP program. This is crucial for establishing your eligibility.
Provide your practice information, including Practice Name, Address, City, State, and Zip Code. Ensure all details are accurate to avoid processing delays.
Select the type of practice (Individual, Facility, or Group) and complete the relevant sections based on your selection.
Enter your Tax ID (EIN or SSN) and Medicare Number if applicable. This information is essential for billing purposes.
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.
Indicate if you have completed a form for Electronic Funds Transfer (EFT) and express interest in electronic billing if desired.
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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Versions	Form popularity	Fillable & printable
2023	4.9 Satisfied (22 Votes)
2020	4.8 Satisfied (90 Votes)
2015	4.4 Satisfied (63 Votes)
2009	4.4 Satisfied (64 Votes)
2004	4.3 Satisfied (46 Votes)

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We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

How do I contact the US Department of Labor?

For answers to general questions about employment laws, workplace issues, or other labor topics, please call our National Contact Center at 1-866-4-USA-DOL (1-866-487-2365).

What is a CA17 form?

It is recommended that you take a Form CA-17 - Duty Status Report with you to give to your physician. This form provides your supervisor and OWCP with interim medical reports containing information as to your ability to return to any type of work.

How do I contact Owcp?

By calling 1-866-OWCP-IVR (1-866-692-7487), injured workers and their representatives may access information regarding case status, compensation payments, reimbursement of treatment and travel expenses, and authorization of medical treatment such as physical therapy and diagnostic testing.

How long can you receive OWCP?

After the initial 45 days, payments decrease to two-thirds of the regular wage amount (three-quarters if the employee has dependents). Compensation continues at this rate for an indefinite length of time based on the extent of the injury and what continued supporting documents the worker can provide.

What is a provider enrollment form?

In the most basic terms, provider enrollment (sometimes referred to as payer enrollment) is the process through which healthcare providers apply to be included in a health insurance network. As an in-network provider, you will be able to treat patients who carry that insurance and be reimbursed for your services.

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