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Get Owcp 1168 2009-2019 Form

2 of the Form OWCP-1168. Please be aware that OWCP in an effort to assist claimants seeking medical services is now providing an on-line search capability by one or more of the following specialty name city state and zip code. Signature Provider or Representative and Title Previous editions unusable Date Form OWCP-1168 Page 1 Revised June 2009 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 list on page 4 the Provider Type code that most closely describes the service s that the professional provides. Check all programs in which you want to enroll as a provider. Indicate earliest date you treated any OWCP beneficiary. Dear Provider Thank you for your interest in participating as a provider of medical services for programs administered by the U.S. Department of Labor s Office of Workers Compensation Programs OWCP. This information will be furnished to OWCP and its data processing contractors and may also be disclosed to other federal and state agencies in connection with the administration of other programs to the Department of Justice for litigation purposes and to medical and other provider review boards. Nor does it guarantee that the medical provider will be reimbursed by OWCP for specific medical services that the provider has billed directly to OWCP or that a medical provider will agree to provide medical services to a particular claimant. Customers using this look-up feature will be advised that this is not an endorsement referral or an agreement to reimburse for medical services rendered as the fact that a provider is listed in no way constitutes an endorsement of the provider or that provider s services by the Department of Labor and OWCP. OWCP has contracted with Affiliated Computer Services ACS to provide medical bill processing services to those three programs. As part of their benefit structure these programs reimburse medical and non-medical providers for services rendered for the care and treatment of a claimant s compensable condition. To process your bills each provider must be enrolled with ACS. Please complete the enclosed provider enrollment form so that a provider identification number can be assigned to you. The OWCP administers the Federal Employees Compensation Act FECA the Black Lung Benefits Act BLBA and the Energy Employees Occupational Illness Compensation Program Act EEOICPA. OWCP has contracted with Affiliated Computer Services ACS to provide medical bill processing services to those three programs. As part of their benefit structure these programs reimburse medical and non-medical providers for services rendered for the care and treatment of a claimant s compensable condition* To process your bills each provider must be enrolled with ACS* Please complete the enclosed provider enrollment form so that a provider identification number can be assigned to you. Instructions for completing the enrollment form and a list of provider types and specialty codes are also included* The Debt Collection Improvement Act of 1996 includes the requirement that payments made by the Federal Government be sent by electronic funds transfer EFT.

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