|
View ESA-OWCP-DCMWC's Form 1215-0137 Online 
| Agency: |
ESA-OWCP-DCMWC |
| Title: |
OWCP-1168, Black Lung Provider Enrollment Form |
| Form Description: |
OWCP-1168, Black Lung Provider Enrollment Form: The information collected on this form will be used to ensure accurate medical provider information for payment of medical and vocational rehabilitation bills. |
| OMB Control Number: |
1215-0137 |
| OMB Expiration Date: |
Wednesday, March 31, 2010
|
| |
|
