01. Edit your provider enrollment information form online
Type text, add images, blackout confidential details, add comments, highlights and more.
Department of labor provider enrollment form 2004-2026
Here's how it works
02. Sign it in a few clicks
Draw your signature, type it, upload its image, or use your mobile device as a signature pad.
03. Share your form with others
Send dol provider enrollment via email, link, or fax. You can also download it, export it or print it out.
How to use or fill out department of labor provider enrollment form 2004 with our platform
Ease of Setup
DocHub User Ratings on G2
Ease of Use
DocHub User Ratings on G2
- 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.
Start using our platform today to fill out your department of labor provider enrollment form quickly and efficiently!
See more provider enrollment information form versions
We've got more versions of the provider enrollment information form form. Select the right provider enrollment information form version from the list and start editing it straight away!
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.
Security and compliance
At DocHub, your data security is our priority. We follow HIPAA, SOC2, GDPR, and other standards, so you can work on your documents with confidence.
People also ask
How do I check the status of my OWCP claim?
Injured Workers, Providers, and Employing Agencies can check on the status of bills and reimbursements on the OWCP Web Bill Processing Portal. Claimant eligibility, bill status, and medical authorization inquiry functionality is also available 24 hours a day via our Interactive Voice Response (IVR) system.
Related links
Provider Enrollment Form. U.S. Department of Labor. Employment Standards June 2004. OMB Number 1215-0137. Expires: 03/31/2007. Page 2. Group ProviderRead more
by EH Board 2004. Department: Labor and Industry. Location: 1306 Labor and Industry Building, Harrisburg, PA 17120. Duration: 1 year duration upon awardRead more
Feb 28, 2026 Indicate by check mark if the registrant is a well-known seasoned issuer, as defined in Rule 405 of the Securities Act. ☒ Yes ☐ No.Read more