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 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 

1a. If Update, Re-Enrollment or Re-Validation, 

 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

(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)

5a. Last Name

5b. First Name

5c. Middle Name 

5d. SSN

6. Organization Information

6a. Organization Name

(Legal Business Name) 

6b. Organization Business Name

 (Doing Business As) 

6c. FEIN 

8. Entity Type

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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(If enrolling using FEIN)

7. National Provider Identifier (NPI)

(Refer to Appendix 3)

(For Update, ONLY complete sections 

you wish to change, then Confirm and 

Sign on page 8.)
 

 

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

11. Location Contact Information

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

11d. Phone Number 11e. Fax Number 

11f. Email Address 

 

 

 

12a. Address Line 1

Address Line 2 

Address Line 3 

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

 

 

 

 

 

 

12. Physical Address

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 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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(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 
 

 

 

 

 

 

 

 

 

 

 

 

 

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

15. Organization Owner

15a. Organization Name 15b. FEIN 

16. Individual Owner

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

17. Address

17a. Address Line 1

Address Line 2 

Address Line 3 

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

17e. County 17f. Country 

Additional Ownership Information 

18. Organization Owner

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 20d. Zip Code 

20e. County 20f. Country 

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(If enrolling using FEIN)

(If enrolling using SSN)

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

 

 

 

 

 

 

 

 

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 21b. Name 

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

21e. Initial Issue Date 21f. Expiration Date 

21g. Issued State 21h. Issuer Agency 

21i. Web Link 

21j. License/Certification not required by State. 

21k. Please explain 

Additional License/Certification 

22a. License/Certification Category 22b. Name 

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

22e. Initial Issue Date 22f. Expiration Date 

22g. Issued State 22h. Issuer Agency 

22i. Web Link 

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(Use additional sheet(s) as required)

(Select if License/Certification is not required by State.)
 

 

 

 

PART F: IDENTIFIERS

23. Provider Identifier Information

23a. Identifier Type 23b. Identifier Value 

23c. Start Date 23d. End Date 

24. Additional Provider identifier information

24a. Identifier Type 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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(Medicare number is required for hospitals (Provider type: 01, 02, 03).)

(Use additional sheet(s) as required)
 

 

 

 

 

 

 

 

 

 

 

 

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 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 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 

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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Signature
 

 

 

 

 

 

 

 

 

 

 

 

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.

Add 2c. Middle Name

2. Individual Information (If enrolling using SSN)

2a. Last 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 5. NPI

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

7. License/Certification Information

ense/

License/Certification Type 

License/

Certification

Number 

Issued 

State 

Initial Issue 

Date 

Expiration

Date 

Additional Addendum Information

1. 

Add 

Update 

Remove 

2. Individual Information (Applicable if enrolling using SSN)

2a. Last Name 2c. Middle Name 

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 5. NPI

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

7. License/Certification Information

License/

Certification

Category 

License/Certification Type 

License/

Certification

Number 

Issued 

State 

Initial Issue 

Date 

Expiration 

Date 

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License/

Certification

Category 
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 2. Name

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

5. Initial Issue Date 6. Expiration Date

7. Issued State 8. Issuer Agency

9. Web Link

1. License/Certification Category 2. Name

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

5. Initial Issue Date 6. Expiration Date

7. Issued State 8. Issuer Agency

9. Web Link

1. License/Certification Category 2. Name

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

5. Initial Issue Date 6. Expiration Date

7. Issued State 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

1.

New Enrollment - New Providers select when not previously enrolled with OWCP

Re-Enrollment - Previously enrolled Provider was excluded, now has become 

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

Required

2.

Select Enrollment Type:

Individual

• 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

or corporation or are employees of a person, partnership or corporation,

or other entity owning or operating the health care facilities at which they

practice. These entities have a Type II National Provider Identifier (NPI)

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.

Required

Refer to Appendix 2 for more 

information

10.

Select this option if you do not wish to be included in the OWCP online 

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

14.

Use Addendum 1 for taxonomy for servicing providers

Use Addendum 2 for additional taxonomy codes. Use additional sheet(s) 

as required.

Refer to Appendix 3 for provider 

type taxonomy requirements

Part D: Ownership Details 

(OPTIONAL)

Part D is optional. 

For DFEC and DEEOIC 

providers, list any 

business with more than a 

5% interest in or where 

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.

• If a license or certification is not required by the State, attach letter/ evidence

from the State authority.

• 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.

Required for Individual and 

Facility/Agency/ 

Organizational enrollment 

types.

21.

• Use Addendum 1 for license and certification information of

servicing providers for group practice enrollment.

• Refer to Addendum 3 to add additional license and certification

information. Use additional sheet(s), as required.

Refer to Appendix 3 for 

requirements

21a.

Type or print license or certification category from following options:

• License

• certification

If submitting a copy of your 

licenses and/or certifications 

skip 21b through 21i

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

25.

Select mode of Submission. Select all applicable options:

Billing For providers who use a 3rd party to bill. 

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

26.

Billing Agent/Clearinghouse information

• Your Billing Agent/Clearinghouse must be enrolled with OWCP first.

• Please obtain the Billing Agent/Clearinghouse’s OWCP ID to complete

this section.

• If they are not yet enrolled, you can still complete your enrollment by

temporarily choosing not to use Billing Agent/Clearinghouse.

• 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 if Billing 

Agent/Clearinghouse selected in 

Part G

Addendum 1: Servicing Providers Information Required for enrollment type 

Group Practice

1.

Select one option to add, update or remove a servicing provider:

• For New Enrollment, only Add action can be selected.

• Type or print all the information for New and Update Action.

• Type or print SSN or FEIN for Remove Action.

• Servicing providers can be enrolled using SSN (individual) or FEIN

(organization).

Required
 

 

 

 

 

 

 

 

 

 

 

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 

Individual 

25, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 40, 41, 42, 43, 44, 47, 50, 51, 

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 

Group Practice 25, 27, 28, 29, 30, 31, 32, 34, 35, 36, 37, 38, 43, 52, 60, 62, 63, 65, 66, 68, 69, 

70, 71, 72, 73, 74, 75, 76, 77, 96 

Facility/Agency/Organization/Institution 01, 02, 03, 05, 20, 40, 42, 43, 44, 46, 50, 51, 53, 55, 57, 58, 59, 65, 66, 68, 69, 

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 

Type NPI required? Taxonomyrequired? 

License/Certification

required? Applicable Program(s) Self-Enrollment 

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 

Type NPI required? Taxonomyrequired? 

License/Certification

required? Applicable Program(s) Self-Enrollment 

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 

Type NPI required? Taxonomyrequired? 

License/Certification

required? Applicable Program(s) Self-Enrollment 

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 

98 All 

** If Self-Enrollment is not allowed for a certain provider type, please contact 1-844-493-1966. 

Previous editions unusable OWCP-1168 

(Revised 12-23)

Page 20