Provider Enrollment form

How to use this form

When & how to file

Quick guide: File this form as instructed by the issuing court or agency. Read the official instructions carefully before submitting.

Jurisdiction: Intended for U.S. federal proceedings. Filing rules may vary by individual court.

Source: Published by US Dept. of Labor — Forms. View on official site →

Important: Verify the form is current with the issuing authority before filing. The wrong version may delay or void your petition.

When to call a lawyer: Consult a licensed attorney if you’re unsure whether this is the right form or how to fill it out.

Form text

Extracted from the official PDF

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Dear New Provider:

Welcome! Thank you for your interest in providing medical services for injured and ill
workers served by the U.S. Department of Labor's Office of Workers' Compensation
Programs (OWCP).

OWCP administers three major compensation programs that provide wage
replacement, medical treatment, pharmaceutical and vocational rehabilitation benefits
to certain workers who experience work-related injuries or occupational disease. These
programs are:
 Division of Federal Employees’ Compensation (DFEC) - Federal Employees Compensation
Act (FECA)
 Division of Energy Employees Occupational Illness Compensation (DEEOIC) - Energy
Employees Occupational Illness Compensation (EEOIC)
 Division of Coal Mine Workers’ Compensation (DCMWC) - Coal Mine Workers’
Compensation (CMWC)

All three programs reimburse medical and non-medical providers for services rendered
for the care and treatment of a claimant’s compensable conditions. Providers can
enroll in any one or more of the three OWCP compensation programs.

To enroll as a provider:
 https://owcpmed.dol.gov/portal/provider/get-started

Detailed provider enrollment instructions can be found using the
online tutorials below:
 Facility Enrollment
https://owcpmed.dol.gov/portal/tutorials/WCMBP_Facility_Provider_Enrollment.pdf
 Group Enrollment
https://owcpmed.dol.gov/portal/tutorials/WCMBP_Group_Provider_Enrollment.pdf
 Individual Enrollment
https://owcpmed.dol.gov/portal/tutorials/WCMBP_Individual_Provider_Enrollment.pdf

For questions about completing the enrollment form, please contact OWCP’s medical
bill processing contractor Enrollment Call Center at 844-493-1966, Monday through
Friday from 8:00 a.m. to 8:00 p.m., Eastern Time.

Upload completed enrollment form and required documents to the Workers
Compensation Medical Bill Processing Portal (WCMBP) https://owcpmed.dol.gov /portal
for enrollment processing. To mail or fax your enrollment form and required documents
use the following:
Mail:
Provider Enrollment
P. O. Box 8312
London, KY 40742-8312

Fax:
888-444-5335

Providers that operate from multiple offices are required to complete a separate
enrollment form for each office location.

Providers who enroll under the group practice (Addendum 1 of the enrollment form) are
not required to enroll separately. Providers are responsible for monitoring the business
licensure for the entity enrolled, as well as the professional licensure for servicing
providers within the practice.

Payments made for your services will be made by electronic fund transfer (EFT) as
required by the Debt Collection Improvement Act of 1996, except for exempt providers.
For EFT, visit Bureau of the Fiscal Service to complete the ACH Vendor/Miscellanous
Payment Enrollment Form.

A remittance notice listing all bills paid on each transaction will be sent to your mailing
address and available through the OWCP Medical Provider Portal.

OWCP provides claimants an online listing of enrolled providers by program, which is
searchable by specialty, name, city, state, and zip code. Claimants are advised that a
provider listing is not an endorsement, referral, or an agreement to reimburse for
medical services rendered by the Department of Labor or OWCP. Also, the listing does
not guarantee claimants that a medical provider will agree to provide medical services
to a particular claimant.

OWCP looks forward to working with you!

NOTICE: Continued participation as a medical provider under the DOL programs above can be
contingent on your maintaining good standing as a medical provider under other federal health benefit
programs such as Medicare. Exclusion as a medical provider in those circumstances operates as an
automatic exclusion under the FECA and EEOICPA. Programs administered by OWCP. (See 20 C.F.R.
§§ 10.815, 30.715, and 702.431). You may also be subject to the federal government’s suspension and
debarment provisions. (See 48 C.F.R. Subpart 9.4 and 2 C.F.R. Part 180).
Provider Enrollment Form Print Reset U.S. Department of Labor

Office of Workers’ Compensation Programs

OMB Number 1240-0021
Expires: 12/31/2026

1. Are you applying for a new enrollment or updating your record?

New Enrollment Re-Enrollment Re-Validation Update (For Update, ONLY complete sections
you wish to change, then Confirm and
1a. If Update, Re-Enrollment or Re-Validation, Sign on page 8.)
Enter Provider ID or Federal Employer Identification Number (FEIN)

PART A: BASIC INFORMATION (All fields in this section are required; if "other" is selected, explanation is required.)

2. Enrollment Type (Refer to Instructions for additional information)
Individual
Group Practice (Please see Page 9 - Addendum 1, for completion of group practice enrollment for each professional)
Facility/Agency/Organization/Institution

3. Provider Type Select
(For multi-specialty group provider, select primary provider type. Refer to Appendix 1 & 3 for more information.)

If selecting “Other Provider” (96) or Non-Medical Vendor (53), please complete 3a.:
3a. Please explain

4. Program (Check the Program(s) in which you want to enroll as a provider.)
DFEC DCMWC DEEOIC DLHWC

5. Individual Information (If enrolling using SSN) Reset
5a. Last Name 5c. Middle Name
5b. First Name 5d. SSN

6. Organization Information (If enrolling using FEIN)
6a. Organization Name
(Legal Business Name)
6b. Organization Business Name 6c. FEIN
(Doing Business As)

7. National Provider Identifier (NPI)
(Refer to Appendix 3)

8. Entity Type Select
8a. If Other, please explain

9. Email Address

10. I do not wish to be included in an online searchable list of OWCP providers.
10a. Reason

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PART B: LOCATION (All fields are required. If not applicable specify N/A.)

11. Location Contact Information (Providers offering services at different location(s) are required to enroll separately for each
location. Servicing providers under a group practice are not required to enroll separately.)

11a. Business Name

11b. Contact Last Name 11c. Contact First Name

11d. Phone Number 11e. Fax Number

11f. Email Address

12. Physical Address

12a. Address Line 1

Address Line 2

Address Line 3

12b. City/Town 12c.State/Province Select 12d. Zip Code

12e. County 12f. Country

13. Mailing Address Same as Physical Address

13a. Address Line 1

Address Line 2

Address Line 3

13b. City/Town 13c. State/Province Select 13d. Zip Code

13e. County 13f. Country

PART C: TAXONOMY (Required if applicable.)

14. Taxonomy a. b. c. d. e.
Code(s)

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PART D: OWNERSHIP DETAILS (Optional. Refer to Instructions for additional information.)

15. Organization Owner (If enrolling using FEIN) Reset

15a. Organization Name 15b. FEIN

16. Individual Owner

16a. Last Name 16b. First Name 16c. SSN

17. Address (If enrolling using SSN)

17a. Address Line 1

Address Line 2

Address Line 3

17b. City/Town 17c. State/Province Select 17d. Zip Code

17e. County 17f. Country

Additional Ownership Information (Section 18 to 20 are for additional ownership information. Use additional sheets as required.)

18. Organization Owner Reset

18a. Organization Name 18b. FEIN

19. Individual Owner

19a. Last Name 19b. First Name 19c. SSN

20. Address

20a. Address Line 1

Address Line 2

Address Line 3

20b. City/Town 20c. State/Province Select 20d. Zip Code

20e. County 20f. Country

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PART E: LICENSE AND CERTIFICATION (Required for Individual and Facility/Agency/Organization enrollment types.
Please refer to Instructions on page 14 for additional information.)
Group practice providers may skip Sections E and F, and continue at Section G through Addendum 1.

21a. License/Certification Category Select 21b. Name

21c. License/Certification Type 21d. License/Certification Number

21e. Initial Issue Date 21f. Expiration Date

21g. Issued State Select 21h. Issuer Agency

21i. Web Link

21j. License/Certification not required by State. (Select if License/Certification is not required by State.)
21k. Please explain

Additional License/Certification (Use additional sheet(s) as required)

22a. License/Certification Category Select 22b. Name

22c. License/Certification Type 22d. License/Certification Number

22e. Initial Issue Date 22f. Expiration Date

22g. Issued State Select 22h. Issuer Agency

22i. Web Link

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PART F: IDENTIFIERS

23. Provider Identifier Information (Medicare number is required for hospitals (Provider type: 01, 02, 03).)

23a. Identifier Type Select 23b. Identifier Value

23c. Start Date 23d. End Date

24. Additional Provider identifier information (Use additional sheet(s) as required)

24a. Identifier Type Select 24b. Identifier Value

24c. Start Date 24d. End Date

PART G: EDI SUBMISSION METHOD

25. Mode of Submission. Check all applicable (See Instructions on page 15 for details regarding modes of submission).

Billing Agent/Clearinghouse Web Interactive FTP Secured Batch
Web Batch None

PART H: EDI SUBMITTER DETAILS (Required if Billing Agent/Clearinghouse selected in Part G).

26. Billing Agent/Clearinghouse/Submitter Information (See Instructions for further details.)

26a. Billing Agent/Clearinghouse OWCP ID

26b. Start Date 26c. End Date

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PART I: EDI CONTACT DETAILS (Required if submitting EDI).

27. EDI Contact Information

27a. Contact Title

27b. Last Name 27c. First Name

27d. Phone Number 27e. Fax Number

27f. Email Address

28. Address

28a. Address Line 1

Address Line 2

Address Line 3

28b. City/Town 28c. State/Province Select 28d. Zip Code

28e. County 28f. Country

29. Additional EDI Contact Information

29a. Contact Title

29b. Last Name 29c. First Name

29d. Phone Number 29e. Fax Number

29f. Email Address

30. Address

30a. Address Line 1

Address Line 2

Address Line 3

30b. City/Town 30c. State/Province Select 30d. Zip Code

30e. County 30f. Country

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Privacy Act Statement
Collection of this information by OWCP is necessary for its administration of the Federal Employees’ Compensation Act, the
Black Lung Benefits Act, the Longshore and Harbor Workers’ Compensation Act and the Energy Employees Occupational
Illness Compensation Program Act, and is authorized under 20 CFR 10.800, 20 CFR 30.700, 20 CFR 702.145, 20 CFR
725.714 and 33 USC 918(b). The information provided will be used to ensure accurate payment of medical and vocational
rehabilitation provider bills and is protected by the Privacy Act of 1974, as amended (5 USC 552a) in accordance with the
following systems of records: DOL/GOVT-1, DOL/OWCP-4 DOL/OWCP-9 and DOL/OWCP-11, published in the Federal
Register, Vol. 81, page 25766, April 29, 2016, or as updated and republished. Completion and submission of this form is
voluntary; however, failure to provide the information (including SSN or FEIN) will result in substantially delayed payment
of bills. 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. Additional disclosures may be made through the routine
uses for information contained in the referenced systems of records.

Public Burden Statement
Under the Paperwork Reduction Act., persons are not required to respond to a collection of information unless such
collection displays a valid OMB control number. We estimate that it will take an average of 25 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.

Notice
If you have a substantially limiting physical or mental impairment, Federal disability nondiscrimination law gives you the right to
receive help from OWCP in the form of communication assistance, accommodation and modification to aid you in the claims
process. For example, we will provide you with copies of documents in alternate formats, communication services such as
sign language interpretation, or other kinds of adjustments or changes to account for the limitations of your disability. Please
contact our office or the claims examiner to ask about this assistance.

Disclosure Statement
Within ten years of the date of this statement have you or any individual listed on this application had an action related to fraud
or abuse in a government program taken against him or her resulting in (1) a felony or misdemeanor conviction; (2) a liability
finding in civil proceedings; or (3) a settlement entered in lieu of conviction? Yes No
If Yes, provide details including type of action, Agency undertaking adverse action and date of action.

Required for DFEC providers
For Provider Type “Medical Supplies/Durable Medical Equipment (DME) / Prosthetics / Orthotics” (75) only:
Are you an accredited DMEPOS supplier enrolled with Medicare? Yes No
If Yes, provide the phone number that you used in your Medicare DMEPOS enrollment.

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Confirm and Sign

I, the undersigned, certify to the following: I have read the contents of this application, and the information contained herein is true, correct, and complete.

I certify that I and my agents have currently in effect all necessary licenses, certifications, approvals, insurance, etc. required to properly provide the services
and/or supplies for the OWCP in the state, county, locality, or jurisdiction where the services and/or supplies are provided. I will provide proof of such licenses,
certifications, approvals, insurance, etc. upon the OWCP's request. I understand that any revocation, withdrawal, or non-renewal of necessary license,
certification, approval, insurance, etc. required for me to properly provide services, shall be grounds for termination of enrollment/registration by the OWCP.

I authorize the OWCP to verify the information contained herein. I agree to notify the OWCP of any change in ownership, practice location and/or Final Adverse
Action involving fraud or abuse within 30 days of the reportable event. In addition, I agree to notify the OWCP of any other changes to the information in this
form within 90 days of the effective date of change.

I also certify that I am not currently sanctioned, suspended, debarred or excluded by any Federal or State Health Care Program, (e.g., Medicare, Medicaid, or
any other Federal program), or otherwise prohibited from providing services to Medicare, Medicaid, or other Federal program beneficiaries nor are any owners,
officers, or managing employees of the practice listed in this application.

I understand that any deliberate omission, misrepresentation, or falsification of any information contained in this application or contained in any communication
supplying information to the Department of Labor, Office of Workers’ Compensation Program (OWCP), or any deliberate alteration of any text on this application
form, may be punished by criminal, civil, or administrative penalties including, but not limited to, the denial or revocation of OWCP billing privileges, civil
damages, and/or imprisonment.

I agree to abide by the OWCP regulations and program instructions that apply to me or to the organization listed in Section 3A of this enrollment form. I
understand that payment of a claim by OWCP is conditioned upon the claim and the underlying transaction complying with state and federal laws (including, but
not limited to, the Federal anti-kickback statute) and OWCP regulations, and program instructions.

I have completed an ACH Vendor Payment/Electronic Fund Transfer (EFT) form. (Please attach ACH form).

Print Name and Title

Signature Date

Print, sign and mail or fax form to the following address:

Provider Enrollment
Department of Labor - OWCP
P. O. Box 8312
London, KY 40742-8312
Fax: 888-444-5335

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Addendum 1: Servicing Providers Information for Group Practice Enrollment
(All fields are required for providers enrolled as Group Practice. Refer to Instructions and Appendices 1 and 3 for additional
information.)
Fill in this addendum to add, update or remove servicing providers for Group Practice. Use additional sheet(s) as required.

1. 2. Individual Information (If enrolling using SSN) Reset

Add 2a. Last Name 2c. Middle Name
Update
Remove 2b. First Name 2d. SSN

3.Organization Information (If enrolling using FEIN)
3a. Organization Name
3b. Organization Business Name 3c. FEIN

4. Provider Type Select 5. NPI

6. Taxonomy a. b. c. d. e.

7. License/Certification Information

License/ License/ Issued Initial Issue Expiration
Certification License/Certification Type Certification State Date Date
Category Number

Select ense/ Others
Select Select

Additional Addendum Information
1. 2. Individual Information (Applicable if enrolling using SSN) Reset
Add
2a. Last Name 2c. Middle Name
Update
Remove 2b. First Name 2d. SSN

3. Organization Information (Applicable if enrolling using FEIN)

3a. Organization Name

3b. Organization Business Name 3c. FEIN

4. Provider Type Select 5. NPI

6. Taxonomy a. b. c. d. e.

7. License/Certification Information

License/ License/ Issued Initial Issue Expiration
Certification License/Certification Type Certification State Date Date
Category Number

Select Select
Select Select

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Addendum 2: Taxonomy Information
Type or print additional Taxonomy information as applicable.
Use additional sheet(s) as required.

Taxonomy

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Addendum 3: License and Certification
Type or print additional license and certification information as applicable.
Use additional sheet(s) as required

1. License/Certification Category Select 2. Name

3. License/Certification Type 4. License/Certification Number

5. Initial Issue Date 6. Expiration Date

7. Issued State Select 8. Issuer Agency

9. Web Link

1. License/Certification Category Select 2. Name

3. License/Certification Type 4. License/Certification Number

5. Initial Issue Date 6. Expiration Date

7. Issued State Others 8. Issuer Agency

9. Web Link

1. License/Certification Category Select 2. Name

3. License/Certification Type 4. License/Certification Number

5. Initial Issue Date 6. Expiration Date

7. Issued State Select 8. Issuer Agency

9. Web Link

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Addendum 4: Billing Agent/Clearinghouse Provider ID
Type or print additional Billing Agent/Clearinghouse Provider IDs as applicable.
Use additional sheet(s) as required.

Billing Agent/Clearinghouse ID Start Date End Date

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Instructions

A brief description and additional information for parts of the form is listed below. Be sure to sign and date the form when you submit it.

Part A: Basic Information

New Enrollment - New Providers select when not previously enrolled with OWCP
1. Re-Enrollment - Previously enrolled Provider was excluded, now has become Required
eligible to enroll with OWCP
Re-Validate - Current Provider who is enrolled with OWCP but has expired
information on the provider enrollment record.
Update - Current Provider who is enrolled with OWCP and needs to update
existing information on the provider enrollment record
Select Enrollment Type:
Individual
2.
• Any provider who is eligible to receive a Type I National Provider
Identifier (NPI) through the National Plan and Provider Enumeration
System (NPPES). Providers eligible to receive an NPI are those who
deliver medical or health services, as defined under Section 1861(s) of
the Social Security Act, 42 U.S.C. 1395x(s).
• Individuals providing only non-medical services, attendant care, or
personal care services, who do not need an NPI.
Group Practice
• One or more health care practitioners who practice their profession at a
common location (whether or not they share common facilities, common
supporting staff, or common equipment) and have formed a partnership Required
or corporation or are employees of a person, partnership or corporation,
or other entity owning or operating the health care facilities at which they Refer to Appendix 2 for more
practice. These entities have a Type II National Provider Identifier (NPI) information
from the National Plan and Provider Enumeration System (NPPES).
Facility/Agency/Organization/Institution
• An Inpatient or Outpatient Hospital, a Skilled Nursing Facility, an
Intermediate Care Facility, a Clinic (RHC, FQHC, Hospital Based Clinic,
Urgent Care), a Psychiatric Facility, a Mental Institution, a Durable
Medical Equipment Supplier, a Free Standing Ambulatory Surgical
Center, a Long Term Care Facility, an Independent Clinical Laboratory, a
Free Standing Radiology, a Dialysis Center, a Pharmacy, a Partnership,
a Corporation, or any other entity that furnishes or arranges for the
furnishing of services for which payment is billed under the OWCP
programs. It does not include individual practitioners or groups of
practitioners. In addition, you must also be eligible to receive and
currently possess, a Type II National Provider Identifier, available
through the National Plan and Provider Enumeration System (NPPES).
• Any entity other than individual who does not deliver medical care or
health services and is thus ineligible for a National Provider Identifier
(NPI) available through the National Plan and Provider Enumeration
System (NPPES). This provider type can include Fiscal
• Intermediaries, Non-Emergency Transportation, etc.

Select this option if you do not wish to be included in the OWCP online
10. searchable program. However, selecting this option will not exclude your
information in a FOIA (Freedom Of Information Act) request.

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Part C: Taxonomy

Use Addendum 1 for taxonomy for servicing providers
Refer to Appendix 3 for provider
14. Use Addendum 2 for additional taxonomy codes. Use additional sheet(s) type taxonomy requirements
as required.

Part D is optional.

For DFEC and DEEOIC
providers, list any
business with more than a
Part D: Ownership Details 5% interest in or where
(OPTIONAL) involvement is at an officer,
director or agent of the
company

Part E: License and Certification

• Please complete and attach copies of all license/certification required by your State
to perform the service under your Provider Type. Required for Individual and
Facility/Agency/
• If a license or certification is not required by the State, attach letter/ evidence Organizational enrollment
from the State authority. types.
• OWCP will verify all your license/certification with your State's license issuer
agency before your enrollment can be approved.
• After your enrollment is approved, you are responsible to keep your
license/certification information up to date.
• Expired license/certification will cause the termination of the provider status.
• If you have a renewed license/certification under a different number, please make sure
to enter it using the exact same License/Certification Type.

• Use Addendum 1 for license and certification information of
servicing providers for group practice enrollment. Refer to Appendix 3 for
21.
• Refer to Addendum 3 to add additional license and certification requirements
information. Use additional sheet(s), as required.

Type or print license or certification category from following options: If submitting a copy of your
21a. • License licenses and/or certifications
skip 21b through 21i
• certification

21k. Type or print Explanation and attach letter/evidence from State authority Required if 21j. is selected

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Part G: EDI Submission Method

Select mode of Submission. Select all applicable options:

Billing For providers who use a 3rd party to bill.
25.
Agent/Clearinghouse

Web Interactive For entering (keying) bills directly in the System.
FTP Secured Batch: For submitting files via an SFTP site.

Web Batch For upload/download of files in the system.

None For submissions through paper form ONLY.

• "Web Batch" method is often used by providers who submit their own
HIPAA batch transactions. It allows a maximum file size of 50 MB.
• Your EDI submission method is "FTP Secured Batch" if you submit
and retrieve batches at a secure web folder assigned to you by
OWCP. This method was designed with clearinghouses and billing
agents in mind. It allows a maximum file size of 100 MB.

• Don't select “None” if other submission method is selected. You can
always submit paper form in addition to EDI Submission.

Part H: EDI Submitter Details

Billing Agent/Clearinghouse information
• Your Billing Agent/Clearinghouse must be enrolled with OWCP first.
26.
• Please obtain the Billing Agent/Clearinghouse’s OWCP ID to complete
this section. Required if Billing
• If they are not yet enrolled, you can still complete your enrollment by Agent/Clearinghouse selected in
temporarily choosing not to use Billing Agent/Clearinghouse. Part G

• You can add them later after they are enrolled with OWCP.
Refer to Addendum 4 for additional information. Use additional sheet(s) as
required.

Required for enrollment type
Addendum 1: Servicing Providers Information
Group Practice

Select one option to add, update or remove a servicing provider:
1. • For New Enrollment, only Add action can be selected.
• Type or print all the information for New and Update Action.
Required
• Type or print SSN or FEIN for Remove Action.
• Servicing providers can be enrolled using SSN (individual) or FEIN
(organization).

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Appendix 1: Provider/Hospital Type Codes

01 General Hospital 63 Optician
02 Special Hospital/ Rehabilitation Facility 65 Home Health Agency
03 Psychiatric Hospital 66 Rural Health Clinic
05 Community Mental Health Center 67 DMA Consult Contractor
20 Pharmacy 68 Federally Qualified Health Center
25 Physician (MD) & Physician (DO) 69 Birthing Center
27 Podiatrist 70 Health Maintenance Organization or
28 Chiropractor Preferred Health Plan
29 Physician Assistant 71 Physical Therapist
30 Advanced Registered Nurse Practitioner 72 Occupational Therapist
(ARNP) 73 Pulmonary Rehabilitation
31 Certified Registered Nurse Anesthetist 74 Outpatient Renal Dialysis Facility
(CRNA) 75 Medical Supplies/Durable Medical
32 Psychologist Equipment (DME) /Prosthetics/Orthotics
33 Contract Medical Consultant 76 Case Management Agency
34 Licensed Midwife 77 Social Worker
35 Dentist 78 Blood Bank
36 Registered Nurse (RN) 80 Pay-to-Intermediary
37 Licensed Practical Nurse (LPN) 88 Ambulatory Surgery Center
38 Nursing Attendant 89 Federal Facility (VA Hospital)
40 Ambulance 90 Skilled Nursing Facility (SNF)-Medicare
41 Contract Nurse Certified & Non-Medicare Certified
42 Air/Water Ambulance Company 92 Intermediate Care Facility (ICF)
43 Taxi 93 Rural Hospital Swing Bed
44 Public Transportation & Private 94 Boarding House
Transportation 95 Insurance Company (Third party Carriers)
46 Hospice 96 Other Provider
47 FOH-DMA Providers 97 Billing Agent
50 Independent Laboratory 98 Lien Holder
51 Portable X-Ray Company
52 Alternative Medicine (e.g., Massage
Therapist/Acupuncturist)
53 Non-Medical Vendor
55 Vocational Rehabilitation (Training, Tuition
and Schools)
56 Vocational Rehabilitation Counselor
57 Rehabilitation Maintenance
58 Assisted Re-employment
59 Relocation Expenses
60 Audiologist/Speech Pathologist
61 Second Opinion Contractor
62 Optometrist
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Appendix 2: Enrollment Type/Provider Type

Applicable provider types for each enrollment type are listed:

Enrollment Type Provider Type

25, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 40, 41, 42, 43, 44, 47, 50, 51,
Individual 52, 53, 55, 56, 57, 58, 59, 60, 61, 62, 63, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74,
75, 76, 77, 78, 80, 88, 95, 96, 98

25, 27, 28, 29, 30, 31, 32, 34, 35, 36, 37, 38, 43, 52, 60, 62, 63, 65, 66, 68, 69,
Group Practice
70, 71, 72, 73, 74, 75, 76, 77, 96

01, 02, 03, 05, 20, 40, 42, 43, 44, 46, 50, 51, 53, 55, 57, 58, 59, 65, 66, 68, 69,
Facility/Agency/Organization/Institution
70, 73, 74, 75, 76, 78, 80, 88, 89, 90, 92, 93, 94, 95, 96, 98

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Appendix 3: Provider Type Matrix

Provider Taxonomy License/Certification Self-Enrollment
NPI required? Applicable Program(s)
Type required? required? allowed? **
01    All 

02    All 

03    All 

05    All 

20    All 

25    All 

27    All 

28    All 

29    All 

30    All 

31    All 

32    All 

33  DEEOIC

34    DFEC 

35    All 

36    All 

37    All 

38    All 

40    All 

41   DFEC

42    All 

43  All 

44  All 

46    All 
Previous editions unusable OWCP-1168
(Revised 12-23)
Page 18
Provider Taxonomy License/Certification Self-Enrollment
NPI required? Applicable Program(s)
Type required? required? allowed? **
47    DFEC
50    All 

51    All 

52    All 

53  All  for DEEOIC

55  DFEC
56  DFEC

57  DFEC
58  DFEC

59 DFEC

60    All 

61    All

62    All 

63    All 

65    All 

66    All 

67    DFEC

68    All 

69    All 

70    All 

71    All 

72    All 

73    All 

74    All 

75    All 

Previous editions unusable OWCP-1168
(Revised 12-23)
Page 19
Provider Taxonomy License/Certification Self-Enrollment
NPI required? Applicable Program(s)
Type required? required? allowed? **
76    All 

77    All 

78    All 

80    All 

88    All 

89    All 

90    All 

92    All 

93    All 

94    All 

95  All 

96    All 

97 All 