en-USApplication for Providers to Enroll en-US(BWC certi037cation not required)en-USSen-USectionen-US 1 226 Pen-USrovideren-US en-UStypeen-USSelect the type that best describes you and submit attachments required for that particular type. þ en-US12 þ Group practice 226 (must attach the name(s) of the en-USBWC-certi037eden-US en-USmember(s), also submit a W-9)en-US þ en-USen-USen-US þ en-US40 þ Hotel/motel 226 approved rehab plan required þ en-US78 þ University and college (rehab-formal training, en-USincluding books and supplies) - services must be en-USpart of an approval rehab retraining program- en-USrehab plan required þ en-US79 þ Rehabilitation 226 non-credentialed services 226 en-USapproved rehab plan required þ en-US80 þ Retail store (rehab) 226 approved rehab plan en-USrequired þ en-US81 þ Rehabilitation 226 unsupervised conditioning en-USfacility 226 approved rehab plan required þ en-US83 þ Rehab transportation (taxis, buses and air travel) en-US226 approved rehab plan required þ en-US99 þ Interpreter - CSS or rehab plan approval en-USMEDCO-13Aen-USBWC-3915 (Rev. Jan. 28, 2019) en-USCheck one of the following and attach required documents. en-USThe 037rst step to becoming enrolled is to complete the en-USApplication for Provider Enrollmenten-US (MEDCO-13A). This form en-USis only applicable to providers who are not required to become BWC certi037ed (see Medco-13 application if your en-USprovider type is not listed in section 1.)en-USWe review all applications to ensure providers meet the minimum enrollment criteria. Providers must meet en-USall licensing, certi037cation or accreditation requirements necessary to provide services. We base minimum en-UScredentials for providers on provider type.en-USNote to pharmacy providers:en-US Pharmacies must apply directly with BWC222s current pharmacy bene037ts manager en-US(PBM) to be issued a BWC provider number. Our current PBM is Change Healthcare. You may contact it through en-USemail at en-USBWCHelpDesk@changehealthcare.comen-US or call 888-292-5229, and request enrollment for the Ohio Bureau en-USof Workers222 Compensation. Each pharmacy provider must send an IRS W-9 to BWC. See the form link and fax en-USnumber below.en-USHave questions? en-USCall 1-800-644-6292, and listen to theen-USoptions to reach BWC222s provider relations departmenten-USbetween 8 a.m. and 5 p.m. weekdays. en-USVisit us on the Internet at: en-USwww.bwc.ohio.gov Return the completed en-USMedco-13Aen-US to:en-USBWC Provider Enrollmenten-USP.O. Box 15249en-USColumbus, OH 43215-0249en-USFax 614-621-1333 en-USImportant remindersen-USAuthorized signature required on each application.en-USInclude the following with your application, if applicable:en-US225 Internal Revenue Service form W-9; en-UShttp://www.irs.gov/pub/irs-pdf/fw9.pdfen-US;en-US225 Workers222 compensation coverage policy;en-US225 National provider identi037cation veri037cation from Fox Systems Inc.;en-US225 Rehab plan or license/accreditation information.en-USApplication foren-USProvider Enrollment-Non Certi037cationen-USProvider Enrollment Application (certi037cation not required) þ n n n en-USMEDCO-13A online form - disabledV3 form American LegalNet, Inc. www.FormsWorkFlow.com en-USSen-USectionen-US 2 226 Gen-USeneralen-US en-USinformation en-USTax identi037cation number en-US(Attach a copy of the IRS form W-9. This number will be used for IRS purposes)en-USTaxonomy code(s) (attach Fox Systems Inc. veri037cation) en-USLegal name associated with tax identi037cation number en-US(Must appear as recognized by the IRS) en-USOwner name(s); de037ne percentage of ownership interest per owneren-USWorkers222 compensation employer policy number, required if you have employees (attach copy of Workers222 Compensation Certi037cate)en-USIndicate the address where you render services, including suite, 036oor, etc. We cannot accept PO Box only for practice location.en-US en-USTelephoneen-USFaxen-US( )en-US( ) en-USNine-digit ZIP codeen-USState en-USCityen-USIndividual provider nameen-US en-US(applicable only for provider types 79 and 99) en-USSocial Security number en-US(Individual must provide Social Security number or individual tax identi037cation number.)en-USMaleen-USFemale en-USBusiness type en-USReimbursement addressen-US en-US(Indicate the address to which we should send all payments, if different from practice address. Include suite, 036oor etc., street address or P.O. Box.) en-USCityen-USCorrespondence address en-US(Indicate the address to which we should send all correspondence, if different from practice address. Include suite, 036oor etc., street address or P.O. Box.) en-USCityen-USPharmacy NCPDP numberen-USLicense/accreditation number, expiration date en-US(If applicable, please attach a copy)en-USMEDCO-13Aen-USCheck here if businessen-UShas no employees en-USGroup/business name and dba name en-US(If applicable)en-USNational provider ID number (attach Fox Systems Inc. veri037cation)en-USCurrent BWC provider numberen-US en-US(if known) en-USNine-digit ZIP codeen-USState en-USNine-digit ZIP codeen-USState en-USContact person en-US(Person completing form)en-USTelephone numberen-USFax numberen-USE-mail addressen-US( )en-US( ) en-USApplicant or authorized personnel signature (Required)en-USPlease print or type name en-USTitle en-USBusiness e-mail address en-USAny personen-US who knowingly makes a false statement, misrepresentation, concealment of fact, or any other act of fraud to obtain payment as provided by BWC, or who knowingly accepts payment to en-USwhich that person is not entitled, is subject to a felony criminal prosecution and may, under appropriate criminal provisions, be punished by a 037ne or imprisonment or both. en-US1en-US2en-US3en-US4en-US5en-US6en-US7en-US8en-US9en-US10en-US11en-US12en-US13en-US14en-US15en-US16en-US17en-US18en-US19en-US20en-US21en-US22en-US23en-US24en-US25en-US26en-US27en-US28en-USDate Individual þ Sole proprietor þ Partnership þ Corporation þ S Corporation þ LLC þ en-US Non-pro037ten-USTitleen-USMEDCO-13Aen-USBWC-3915 (Rev. Jan. 28, 2019) American LegalNet, Inc. www.FormsWorkFlow.com