Application for en-USProvider Enrollment and Certi037cationen-USThe 037rst step to becoming BWC certi037ed is to complete the en-USApplication for Provider en-USEnrollment and Certi037cationen-US (MEDCO-13).en-USWe review all applications to ensure eligible providers meet the minimum enrollment en-USand certi037cation criteria. Providers must meet all licensing, certi037cation or accreditation en-USrequirements necessary to provide services. We establish minimum credentials for en-USproviders based on the provider type.en-USOnce the certi037cation process is completed, we will include your name on the provider en-USlook-up on en-USwww.bwc.ohio.gov. en-USWe also will provide your name to the managed care en-USorganizations (MCOs) responsible for managing the medical portion of BWC222s workers222 en-UScompensation claims. Have questions? en-USCall 1-800-644-6292,en-USand listen to the options to reachen-USBWC222s provider relations department,en-USbetween 8 a.m. and 5 p.m. weekdays. en-USVisit us on the Internet at:en-USwww.bwc.ohio.goven-USAuthorized signature required on each application/agreement.en-USPlease include the following with your application/agreement, if applicable: 225 � State licensure or accreditation/certi037cation document copy with number and � en-USexpiration date; 225 � en-USBoard or diplomate certi037cate, if applicable; 225 � en-USDrug Enforcement Administration registration, if applicable; 225 � en-USInternal Revenue Service (IRS) W-9; http://www.irs.gov/pub/irs-pdf/fw9.pdf; 225 � en-USWorkers222 compensation coverage policy; 225 � en-USNational Provider Identi037er veri037cation (from NPI enumerator), if applicable; 225 � en-USProof of telemedicine certi037cate from Medical Board or acupuncture certi037cate from en-USChiropractic Board, if applicable; 225 � en-USPhysician declared practice specialty (en-USrequireden-US M.D./DOs). Important reminders All provider types are not required to become BWC certi037ed. en-USIf you do not 037nd your provider type in Section 1 of the en-USapplication, please see the MEDCO-13A form available at en-USwww.bwc.ohio.gov. Completing the MEDCO-13 225 � en-USPlease print or type. 225 � en-USPlease complete one application/agreement en-USper federal tax identi037cation number. 225 � en-USList all practice locations (use separate sheet en-USif needed). 225 � en-USComplete a separate application/agreement en-USfor each individual member of a group en-USphysician practice. 225 � en-USReturn the completed application/agreement to:en-USBWC Provider Enrollmenten-USP.O. Box 15249en-USColumbus, OH 43215-0249en-USFax 614-621-1333 Provider Enrollment and Certi037cation en-USMEDCO-13 online form - disabled American LegalNet, Inc. www.FormsWorkFlow.com en-USSen-USectionen-US 1 226 Pen-USrovideren-US en-UStypeen-USSelect the type that best describes you and complete sections requested for that particular type.en-USIf you do not 037nd your provider type, see the MEDCO-13A form available at www.bwc.ohio.gov.en-USApplication foren-USProvider Enrollment and Certi037cationen-USMEDCO-13en-USBWC-3913 (Rev. Jan. 11, 2018) en-USIf you check one of the following, complete sections 2, 3, 4 and 5 and attach required documents. � en-US04 � Audiologist 226 State speech and hearing professionals board � � license � en-US05 � Non-physician acupuncturist 226 Applicable state medical � � board registration � en-US07 � Anesthesiologist assistant 226 Certi037cate of registration from � � state medical board � en-US09 � Chiropractor (DC) 226 State chiropractic board license; state � � board acupuncture certi037cate if applicable � en-US14 � Physician assistant 226 NCCPA certi037cation and license to � � practice from OSMB � en-US15 � Dentist (DDS) 226 State dental board license � en-US20 � Ocularist 226 State vision professionals board license � en-US27 � Hearing aid dealer/dispenser 226 State speech and hearing � � professionals board license � en-US28 � Certi037ed shoe retailer 226 Pedorthic Footwear Association � � certi037cation � en-US33 � Advanced practice nurse (clinical nurse specialist and � � certi037ed nurse practitioner) 226 ANCC certi037ed equivalent and � � certi037cate of authority from state nursing board � en-US48 � Massage therapist/massotherapist 226 State medical board � � license � en-US52 � Nurse anesthetist 226 AANA or CRNA certi037cation and � � certi037cate of authority from state nursing board � en-US57 � Occupational therapist 226 State occupational therapy, physical � � therapy and athletic trainers board license � en-US58 � Optician 226 State vision professionals board license � en-US59 � Optometrist (OD) 226 State vision professionals board license � en-US65 � Physical therapist (LPT) 226 State occupational therapy, � � physical therapy and athletic trainers board license � en-US66 � Physician (DO) 226 State board license 226 state board � � telemedicine certi037cate if applicable � en-US67 � Physician (M.D.) 226 State board license 226 state board � � telemedicine certi037cate if applicable � 68 � Athletic trainer 226 License from the state occupational therapy, � � physical therapy and athletic trainers board � en-US70 � Podiatrist (DPM) 226 State board license � en-US71 � Prosthetist/orthotist/pedorthist (CO, CP, COP) 226 License from � � OHIO OT, PT, AT board � en-US72 � Psychologist (PhD) 226 State board license � en-US76 � Vocational rehabilitation 226 Vocational case management � � 226 ABVE, COHN, CRC, CRRN, CVE, CDMS or CCM credentials � en-US84 � Professional counselor (licensed) and social worker (licensed) � � Ohio counselor, social worker, and MFT board license � en-US86 � Employment specialist 226 (individual) ABVE, CRC, CCM, GCDF, � � ACC, PCC, MCC, CDMS or CARF individual accreditation for � � employment and community services in job development or � � employment supports; OR educational courses 226 addendum � � sent upon receipt � en-US88 � Professional clinical counselor (licensed) and independent � � social worker (licensed) Ohio counselor, social worker, and � � � MFT board license � en-US89 � Speech 226 Language pathologist 226 state speech and � � hearing professionals board � en-US90 � Ergonomist 226 CPE; CHFP, AEP, AHFP, CEA, CSP with � � ergonomics specialist designation, CIE, CIH, ATP or RET � en-US01 � Air ambulance 226 Private: license from Ohio Medical � � Transportation Board; public/government: Medicare � � participation � en-US02 � Ambulance/Ambulette service 226 Private: license from Ohio � � Medical Transportation Board; public/government: Medicare � � participation � en-US03 � Ambulatory surgical center: Ohio Department of Health � � license and Medicare participation � en-US08 � Adult day care facility 226 Ohio Department of Aging Passport � � adult day care provider agreement � en-US10 � Clinic 226 Drug/alcohol (free standing) 226 Ohio Mental Health and � � Addiction Services certi037cation � en-US11 � Pain clinic (free standing) 226 CARF accreditation; hospital � � based, CARF or Joint Commission accreditation � en-US13 � ASC Arthroplasty Center 226 Ohio Department of Health license � � and Medicare participation AND complete application � � addendum that will be sent upon receipt � en-US16 � Dialysis center/ESRD clinic (free standing) 226 Ohio Department � � of Health certi037cation and Medicare participation � en-US17 � Durable medical equipment supplier 226 Ohio board of � � pharmacy home medical equipment certi037cate of registration � � and Medicare participation � en-US18 � Sleep lab 226 Certi037cation from American Academy of Sleep � � Medicine and Medicare participation � en-US19 � Independent Diagnostic Testing Facility 226 Medicare � � participation � en-US30 � Home health agency 226 Medicare participation (directly or � � through agency with 223deeming224 CMS authority), � � Joint Commission or CHAP accreditation � en-US32 � (HHA) Hospice 226 Ohio Department of Health license and � � Medicare/Medicaid participation � en-US34 � Hospital 226 General/acute 226 Joint Commission accreditation, � � AOA HFAP accreditation or Medicare participation, *Note: � � Hospital provider based urgent care centers/clinics should � � enroll under appropriate