Provider Enrollment Form U.S. Department of Labor Employment Standards Administration Office of Workers' Compensation Programs OMB Number 1215-0137 Expires: 03/31/2010 Please refer to instructions for completing this form. Provider Number Effective Date FOR DOL USE ONLY 1. Are you applying for a new enrollment or updating your record? If update, enter Provider Number or EIN: 2. What is the earliest date that you treated a participant in any OWCP program? New enrollment Update Practice Information 3. Practice Name 4. 5. City 6. State 8. Telephone 9. FAX 10. Type of Practice a. c. b. Individual Address 7. Zip (9 digits) facility (For Individual or Facility, complete indicated sections below) Group (Please see reverse for completion of group enrollment) Provider Type (Individual or Facility) 11b. Provider Type 11a. Provider Type Number 11c. If you select "Other Provider" (96) or Non-Medical Vendor (53), please explain: 12. Tax ID: EIN SSN 13. Required for hospitals only: 13a. Medicare Number 13b. NPI: 13c. Taxonomy Code(s): 1. 1. 2. 2. 3. 3. License and Certification (Individual for M.D. and D.O. only) 14a. Name 14b. License #/ State 14e. Certification Expiration Date 14c. Current Lic Expiration Date 14d. Specialty Code(s) 16c. State 16d. Zip (9 digits) 15. United Mine Workers' of American (UMWA) Number, if applicable: Billing Address-indicate "same" if identical to Practice Address. 16a. Address 16b. City 17. I have completed a form for Electronic Funds Transfer (EFT). 18. I am interested in billing electronically NOTICE: Anyone who misrepresents or falsifies essential information to receive payment from Federal funds may upon conviction be subject to fine and imprisonment under applicable Federal laws. Signature (Provider or Representative and Title) Date Form OWCP-1168 American LegalNet, Inc. www.FormsWorkflow.com Rev. June 2006 Group Provider Enrollment - #10c For group practice enrollment, please enter the following information for each professional who will provide services under the group EIN. Select from the attached list the Provider Type code that most closely describes the service(s) that the professional provides. Attach separate sheet for additional entries if necessary. Name SSN # Prov Type License #/ State Current Lic# Exp Date Specialty Code(s) Certification Exp Date Code Please return this completed form to the appropriate program at the following address to prevent a delay in the processing of your bills. For Federal Employees' Compensation Act (FECA) Program: For Black Lung Program: For Energy Program: For Longshore Program: ACS P.O. Box 14600 DOL Black Lung Program P.O. Box 13200 Tallahassee, FL 32317-4600 Tallahassee, FL 32317-3200 DOL Energy Program P.O. Box 13400 Tallahassee, FL 32317-3400 Division of Longshore and Harbor Workers' Compensation 200 Constitution Avenue, Room C-4315 Washington, D.C. 20210 If you have any questions regarding the completion If you have any questions regarding the completion of the form, please call Toll Free: 1-800-638-7072 If you have any questions regarding the completion If you have any questions regarding the completion of the form, please call Toll Free: 1-866-335-8319 of the form, please call; 1-202-693-0925 of the form, please call Toll Free: 1-866-335-8319 Privacy Act Statement (1) Collection of this information is authorized by the Federal Employees' Compensation Act (20 CFR 10.801), the Black Lung Benefits Act (20 CFR 725.704 and 725.705), the Energy Employees Occupational Illness Compensation Program Act of 2000 (20 CFR 30.701). (2) The information collected on this form will be used to ensure accurate medical provider information for payment of medical and vocational rehabilitation bills. (3) Disclosure of your Social Security Number and completion of this form is voluntary; however, failure to provide the information may result in bill payment delays. (4) This information may be furnished to data processing contractors, to the Department of Labor and to the IRS in accordance with law. (5) Furnishing all requested information will facilitate accurate and timely payment for services to the provider. Public Burden Statement We estimate that it will take an average of 8 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 Form OWCP-1168 Rev. June 2006 American LegalNet, Inc. www.FormsWorkflow.com Provider Enrollment Form (Instructions) A brief description of each data element is listed below. Be sure to sign and date the form when you submit it. For further information contact ACS or OWCP at the telephone numbers indicated o n the form. Block 1 Indicate whether this form is being used for a new enrollment, or to update an existing enrollment record. If the form is being submitted to update your record, enter your Provider Number or EIN. Block 2 Indicate earliest date you treated any OWCP beneficiary. Block 3 Type or print your practice name. Block 4 Type or print your practice street address. Block 5 Type or print your practice city. Block 6 Type or print your practice state. Block 7 Type or print your practice zip code (all nine digits). Block 8 Type or print your practice telephone number. Block 9 Type or print your practice FAX number (if applicable). Block 10 Check your practice type-"a" for individual practice, "b" for a facility, or "c" for a group practice. Black Lung only: providers should disregard group practice information. If you checked "c" (group practice), fill out the appropriate parts of Block 10c on the reverse of the form for each professional that will be providing services under the group Provider Number (name, Social Security number, provider type code from list below, license number and State, expiration date of current license, specialty code or codes from the list below, and the date any certification expires). Continue on a separate sheet if necessary. Block 11a If you checked "a" or "b" (individual practice or facility) in Block 10, type or print your "Provider Type" code from the list below. Block 11b If you checked "a" or "b" (individual practice or facility) in Block 10, type or print the "Provider Type" that corresponds with the code you entered in Block 11a. Block 11c If you checked "a" or "b" (individual practice or facility) in Block 10 and selected "Other Provider" (code 96) or "Non-Medical Vendor (code 53), please explain why you are enrolling. Block 12 If you checked "a" or "b" (individual practice or facility) in Block 10, type or print your Social Security number and/or your EIN, as appropriate. Block 13 Blocks 13a thru 13c are required for hospitals only. Block 13a If you checked "b" (facility) in Block 10, type or print your Medicare number. Block 13b Type or print your National Provider Identifier (NPI). If you are a medical provider and you do not have an NPI, you can apply for one via the web at https://nppes.cms.hhs.gov. You can also apply via paper enrollment form CMS-101114. The completed form should be sent to: NPI Enumerator P.O. Box 6059 Fargo, ND 58108-6059 Block 13c Type or print the taxonomy or taxonomies that correspond to the NPI you have entered. This is required for medical providers who have an NPI. You should use the taxonomy values that you submitted when applying for your NPI. More information on provider taxonomy is available at www.wpc-edi.com/taxonomy. American LegalNet, Inc. www.FormsWorkflow.com Block 14a If you checked "a" (individual practice) in Block 10 and you are an M.D. or a D.O, type or print your name. Block 14b If you checked "a" (individual practice) in Block 10 and you are an M.D. or a D.O, type or print your license number and State. Attach a copy of current M.D. or D.O. license. Block 14c If you checked "a" (individual practice) in Block 10 and you are an M.D. or a D.O, type or print the expiration date of your current license. This license must be kept current to continue receiving payment. Block 14d If you checked "a" (individual practice) in Block 10 and you are an M.D. or a D.O, type or print your specialty code or codes from the list below. Block 14e If you checked "a" (individual practice) in Block 10 and you are an M.D. or a D.O, type or print the expiration date of any certification you currently hold. Block 15 Type or print your UMWA Health & Retirement Funds Member Number, if any. Block 16a Type or print the address where you want your Remittance Advices and paper checks to be sent. If this address is identical to your billing address above in Blocks 4 through 7, indicate "same" and skip Blocks 16b, 16c and 16d. Block 16b Type or print your billing city if this is different from Block 5. Block 16c Type or print your billing State if this is different from Block 6. Block 16d Type or print your billing zip code (all nine digits) if this is different from Block 7. Block 17 Indicate whether you have also completed a form for Electronic Funds Transfer (EFT). Block 18 Indicate whether you are interested in billing electronically. ******* Provider Type Codes (Blocks 10c, 11a and 11b) 01 02 03 05 19 20 25 26 27 28 29 30 31 32 34 35 36 37 38 39 General Hospital Special Hospital/Outpatient Rehabilitation Facility Psychiatric Hospital Community Mental Health Center End Stage Renal Hospital Pharmacy Physician (MD) Physician (DO) Podiatrist Chiropractor Physician Assistant Advanced Registered Nurse Practitioner (ARNP) CRNA Psychologist Licensed Midwife Dentist Registered Nurse (RN) Licensed Practical Nurse (LPN) Nursing Attendant Massage Therapist American LegalNet, Inc. www.FormsWorkflow.com 40 41 42 43 44 45 46 50 51 52 53 54 55 56 57 58 59 60 61 62 63 65 66 68 69 70 71 72 73 74 75 76 77 78 79 80 88 89 90 91 92 93 94 95 96 97 98 Ambulance Contract Nurse Air/Water Ambulance Company Taxi Public Transportation Private Transportation Hospice Independent Laboratory Portable X-Ray Company Alternative Medicine Non-Medical Vendor Prosthetics/Orthotics Vocational Rehabilitation (Training, Tuition and Schools) Vocational Rehabilitation Counselor Rehabilitation Maintenance Assisted Re-employment Relocation Expenses Audiologist/Speech Pathologist Second Opinion Contractor Optometrist Optician Home Health Agency Rural Health Clinic Federally Qualified Health Center Birthing Center HMO or PHP Physical Therapist Occupational Therapist Pulmonary Rehabilitation Outpatient Renal Dialysis Facility Medical Supplies/Durable Medical Equipment (DME) Case Management Agency Social Worker Blood Bank Alternative Payee Pay-to-Intermediary Ambulatory Surgery Center Federal Facility (VA Hospital) Skilled Nursing Facility (SNF)-Medicare Certified Skilled Nursing Facility (SNF)-Non-Medicare Certified Intermediate Care Facility (ICF) Rural Hospital Swing Bed Boarding House Insurance Company (Third Party Carriers) Other Provider Billing Agent Lien holder American LegalNet, Inc. www.FormsWorkflow.com ******* Provider Specialty Codes (Blocks 10c and 14d) 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 20 21 22 24 25 26 27 28 29 30 31 32 33 34 40 41 42 44 45 46 47 48 50 Adolescent Medicine Allergy Anesthesiology Cardiovascular Disease Dermatology Diabetes Emergency Medicine Endocrine Medicine Family Practice Gastroenterology General Practice Preventative Medicine Geriatrics Gynecology Hematology Immunology Infectious Diseases Internal Medicine Neoplastic Diseases Nephrology Neurology Neuropathology Nutrition Obstetrics Obstetrics and Gynecology Occupational Medicine Oncology Ophthalmology Otolaryngology Pathology Pathology, clinical Pathology, forensic Pharmacology Physical medicine and rehab Psychiatry Psychoanalysis Public Health Pulmonary diseases Radiology Diagnostic radiology Therapeutic radiology 51 52 53 54 55 56 57 58 60 61 62 63 64 65 70 71 72 74 75 76 77 78 80 82 84 85 86 88 90 91 92 93 95 96 97 98 99 Rheumatology Abdominal surgery Cardiovascular surgery Colon and rectal surgery General surgery Hand surgery Neurological surgery Orthopedic surgery Plastic surgery Thoracic surgery Traumatic surgery Urological surgery Other physician specialty Maternal fetal medicine Adult, dentures only General dentist Oral surgeon, dentist Other dentist Adult primary care nurse practitioner Clinical nurse specialist College nurse practitioner Diabetic nurse practitioner Family/Emergency nurse Geriatric nurse practitioner Nurse anesthesiologist Nurse midwife OB/GYN nurse practitioner Orthodontist Occupational therapist Physical therapist Speech therapist Respiratory therapist Aged/disable waiver Develop services waiver Channeling waiver Comm supp living arrangement Other American LegalNet, Inc. www.FormsWorkflow.com