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 þ State licensure or accreditation/certi037cation document copy with number and þ en-USexpiration date; 225 þ en-USBoard or diplomate certi037cate, if applicable; 225 þ en-USDrug Enforcement Administration registration, if applicable; 225 þ en-USInternal Revenue Service (IRS) W-9; http://www.irs.gov/pub/irs-pdf/fw9.pdf; 225 þ en-USWorkers222 compensation coverage policy; 225 þ en-USNational Provider Identi037er veri037cation (from NPI enumerator), if applicable; 225 þ en-USProof of telemedicine certi037cate from Medical Board or acupuncture certi037cate from en-USChiropractic Board, if applicable; 225 þ 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 þ en-USPlease print or type. 225 þ en-USPlease complete one application/agreement en-USper federal tax identi037cation number. 225 þ en-USList all practice locations (use separate sheet en-USif needed). 225 þ en-USComplete a separate application/agreement en-USfor each individual member of a group en-USphysician practice. 225 þ 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. þ en-US04 þ Audiologist 226 State speech and hearing professionals board þ þ license þ en-US05 þ Non-physician acupuncturist 226 Applicable state medical þ þ board registration þ en-US07 þ Anesthesiologist assistant 226 Certi037cate of registration from þ þ state medical board þ en-US09 þ Chiropractor (DC) 226 State chiropractic board license; state þ þ board acupuncture certi037cate if applicable þ en-US14 þ Physician assistant 226 NCCPA certi037cation and license to þ þ practice from OSMB þ en-US15 þ Dentist (DDS) 226 State dental board license þ en-US20 þ Ocularist 226 State vision professionals board license þ en-US27 þ Hearing aid dealer/dispenser 226 State speech and hearing þ þ professionals board license þ en-US28 þ Certi037ed shoe retailer 226 Pedorthic Footwear Association þ þ certi037cation þ en-US33 þ Advanced practice nurse (clinical nurse specialist and þ þ certi037ed nurse practitioner) 226 ANCC certi037ed equivalent and þ þ certi037cate of authority from state nursing board þ en-US48 þ Massage therapist/massotherapist 226 State medical board þ þ license þ en-US52 þ Nurse anesthetist 226 AANA or CRNA certi037cation and þ þ certi037cate of authority from state nursing board þ en-US57 þ Occupational therapist 226 State occupational therapy, physical þ þ therapy and athletic trainers board license þ en-US58 þ Optician 226 State vision professionals board license þ en-US59 þ Optometrist (OD) 226 State vision professionals board license þ en-US65 þ Physical therapist (LPT) 226 State occupational therapy, þ þ physical therapy and athletic trainers board license þ en-US66 þ Physician (DO) 226 State board license 226 state board þ þ telemedicine certi037cate if applicable þ en-US67 þ Physician (M.D.) 226 State board license 226 state board þ þ telemedicine certi037cate if applicable þ 68 þ Athletic trainer 226 License from the state occupational therapy, þ þ physical therapy and athletic trainers board þ en-US70 þ Podiatrist (DPM) 226 State board license þ en-US71 þ Prosthetist/orthotist/pedorthist (CO, CP, COP) 226 License from þ þ OHIO OT, PT, AT board þ en-US72 þ Psychologist (PhD) 226 State board license þ en-US76 þ Vocational rehabilitation 226 Vocational case management þ þ 226 ABVE, COHN, CRC, CRRN, CVE, CDMS or CCM credentials þ en-US84 þ Professional counselor (licensed) and social worker (licensed) þ þ Ohio counselor, social worker, and MFT board license þ en-US86 þ Employment specialist 226 (individual) ABVE, CRC, CCM, GCDF, þ þ ACC, PCC, MCC, CDMS or CARF individual accreditation for þ þ employment and community services in job development or þ þ employment supports; OR educational courses 226 addendum þ þ sent upon receipt þ en-US88 þ Professional clinical counselor (licensed) and independent þ þ social worker (licensed) Ohio counselor, social worker, and þ þ þ MFT board license þ en-US89 þ Speech 226 Language pathologist 226 state speech and þ þ hearing professionals board þ en-US90 þ Ergonomist 226 CPE; CHFP, AEP, AHFP, CEA, CSP with þ þ ergonomics specialist designation, CIE, CIH, ATP or RET þ en-US01 þ Air ambulance 226 Private: license from Ohio Medical þ þ Transportation Board; public/government: Medicare þ þ participation þ en-US02 þ Ambulance/Ambulette service 226 Private: license from Ohio þ þ Medical Transportation Board; public/government: Medicare þ þ participation þ en-US03 þ Ambulatory surgical center: Ohio Department of Health þ þ license and Medicare participation þ en-US08 þ Adult day care facility 226 Ohio Department of Aging Passport þ þ adult day care provider agreement þ en-US10 þ Clinic 226 Drug/alcohol (free standing) 226 Ohio Mental Health and þ þ Addiction Services certi037cation þ en-US11 þ Pain clinic (free standing) 226 CARF accreditation; hospital þ þ based, CARF or Joint Commission accreditation þ en-US13 þ ASC Arthroplasty Center 226 Ohio Department of Health license þ þ and Medicare participation AND complete application þ þ addendum that will be sent upon receipt þ en-US16 þ Dialysis center/ESRD clinic (free standing) 226 Ohio Department þ þ of Health certi037cation and Medicare participation þ en-US17 þ Durable medical equipment supplier 226 Ohio board of þ þ pharmacy home medical equipment certi037cate of registration þ þ and Medicare participation þ en-US18 þ Sleep lab 226 Certi037cation from American Academy of Sleep þ þ Medicine and Medicare participation þ en-US19 þ Independent Diagnostic Testing Facility 226 Medicare þ þ participation þ en-US30 þ Home health agency 226 Medicare participation (directly or þ þ through agency with 223deeming224 CMS authority), þ þ Joint Commission or CHAP accreditation þ en-US32 þ (HHA) Hospice 226 Ohio Department of Health license and þ þ Medicare/Medicaid participation þ en-US34 þ Hospital 226 General/acute 226 Joint Commission accreditation, þ þ AOA HFAP accreditation or Medicare participation, *Note: þ þ Hospital provider based urgent care centers/clinics should þ þ enroll under appropriate