Complete Section A if you are an INDIVIDUAL PROVIDER enrolling to provide services for one of the Department of Labor Office of Workers’ Compensation Programs: FECA, Energy, or Black Lung. Please Note: You are required to fill out an ACH form. Please type or print application. Section A Individual Provider – Pending OMB Review 1. Check the appropriate application type: New Enrollment_______ Re-Enrollment____ or Update_______ 2. If this is a Re-Enrollment please provide your current DOL Provider Number 3. DOL Program Name (please check all that apply) (FECA, ____ Energy, _____ Black Lung____) 4. Practice Name 4a. DBA Practice Name 5. Provider Name Last, First, Middle 5a. Provider DOB _ _/_ _/_ _ _ _ (MM/DD/YYYY) 5b. Provider SSN _ _ _ - _ _ - _ _ _ _ 6. Practice Physical Street Address 6a. City 6b. State 6c. Zip Code _ _ _ _ _ - _ _ _ _ (9 digit) 6d. Telephone (Physical Practice Location) 6e. FAX No: 6f. Practice Contact Person Name and Title 6g. Practice Contact Person Phone Number and Email Address 7. Practice Billing Address 7a. City 7b. State 7c. Zip Code _ _ _ _ _ - _ _ _ _ (9 digit) 8. Bank Name 8a. Address (Branch) 8b. City 8c. State 8d. Zip Code _ _ _ _ _ - _ _ _ _ (9 digit) 8e. Banking Contact Person and Title 8f. Banking Contact Person Phone Number and Email Address 9. Provider Tax ID/EIN _ _ _ _ _ _ _ _ _ (9 digit) 10. Provider DEA #_ _ _ _ _ _ _ _ _ (2 letters+7 digit). 11. NPI# _ _ _ _ _ _ _ _ _ _ _ (10 digit type 1) 12.Taxonomy# _ _ _ _ _ _ _ _ _ _ (10 digit) 13. License and/or Certification required for Applicant
Complete Section A if you are an INDIVIDUAL PROVIDER enrolling to provide services for one of the Department of Labor Office of Workers’ Compensation Programs: FECA, Energy, or Black Lung. Please Note: You are required to fill out an ACH form. Please type or print application. Section A – Individual Provider Pending OMB Review 1. Check the appropriate application type: New Enrollment_______ Re-Enrollment____ or Update_______ 2. If this is a Re-Enrollment please provide your current DOL Provider Number 3. DOL Program Name (please check all that apply) (FECA, ____ Energy, _____ Black Lung____) 4. Practice Name 4a. DBA Practice Name 5. Provider Name Last, First, Middle 5a. Provider DOB _ _/_ _/_ _ _ _ (MM/DD/YYYY) 5b. Provider SSN _ _ _ - _ _ - _ _ _ _ 6. Practice Physical Street Address 6a. City 6b. State 6c. Zip Code _ _ _ _ _ - _ _ _ _ (9 digit) 6d. Telephone (Physical Practice Location) 6e. FAX No: 6f. Practice Contact Person Name and Title 6g. Practice Contact Person Phone Number and Email Address 7. Practice Billing Address 7a. City 7b. State 7c. Zip Code _ _ _ _ _ - _ _ _ _ (9 digit) 8. Bank Name 8a. Address (Branch) 8b. City 8c. State 8d. Zip Code _ _ _ _ _ - _ _ _ _ (9 digit) 8e. Banking Contact Person and Title 8f. Banking Contact Person Phone Number and Email Address 9. Provider Tax ID/EIN _ _ _ _ _ _ _ _ _ (9 digit) 10. Provider DEA #_ _ _ _ _ _ _ _ _ (2 letters+7 digit). 11. NPI# _ _ _ _ _ _ _ _ _ _ _ (10 digit type 1) 12.Taxonomy# _ _ _ _ _ _ _ _ _ _ (10 digit) 13. License and/or Certification required for Applicant
FECA_Individual%20Provider%20Reenrollment%20Application.docx