BI-210apr Application for Provider Registration New Registration 01/06 Return completed form to: BrickStreet Mutual Insurance Provider Registration Unit P.O. Box 1023 Charleston WV 25324-1023 Re-Registration Effective date of service with BrickStreet Insurance: Business Name: USE BLACK INK ATTACH A COMPLETED AND SIGNED W-9 FORM. Tax ID: Contact Name: Contact Phone: Contact Fax: Physical Location: City: State: Zip: State: Zip: Remittance Address: City: Correspondence Address: City: State: Zip: Phone: Fax: For EFT: Account Number : Routing Number: Is this one-time service? Date(s) of Service: For West Virginia businesses--BrickStreet Policy No.: SOLE PROPRIETOR ONLY – I elected not to have workers’ compensation employer coverage. Yes No Title: SSN: ASSOCIATE INFORMATION (IF APPLICABLE) Associate’s Name: State of Licensure: License No.: (Please include current copy of professional license.) Expiration Date: UPIN: DEA No.: (Please include current copy of DEA cert.) Has your professional license ever been restricted or revoked? Yes No Have your hospital privileges ever been restricted or revoked? Yes No Have you ever been barred from Medicare, Medicaid, PEIA or WV Workers' Compensation? Have you ever been barred from any federal agency or program? Yes Yes No No (If the answer to any of the above questions is yes, you must attach an explanation.) Board Certified? Yes No Certification Date: (Please include copy of board certification) Board Name: Expiration Date: Specialty: BrickStreet Mutual Insurance P.O. Box 1023 Charleston, WV 25324 - 1023 American LegalNet, Inc. www.FormsWorkflow.com Practice Type: Code Practice Type Provider Specialty: Code Provider Specialty Type Code Provider Specialty Type Individual Practice 1 Acute Hospitals 44 Union Representatives 2 Partnership 2 Pharmacy 48 Neurological Surgery 3 Corporation 3 Outpatient Centers and Clinics 51 Optometry 4 Group Practice 4 General Surgery 52 Chronic Pain Facilities 5 Pharmacy Chain 5 Psychiatry & Psychology 54 Household Modification 6 Clinic 6 Orthopedics & Orthopedic Surgery 55 Employer 7 Nonprofit Organization 7 General & Family Practice 68 Vocational Retraining 8 VENDOR INFORMATION (PLEASE USE LISTING OF PRACTICE TYPES AND SPECIALTY CODES ) 1 Limited Liability Company 8 Ophthalmology 71 Misc. *Must explain specialty 9 Dermatology 72 Obstetrics & Gynecology 10 Internal Medicine 74 Emergency & Critical Care 11 Plastic Surgery 75 Rheumatology 12 Cardiology 76 Hearing Aid Dealers 13 Dentistry & Dental Surgery 80 Court Reporting 14 Radiology 82 Hematology & Oncology 16 Chiropractic Services 83 Widow and Widower 17 Rehab. Services 86 Psychiatric Hospitals 18 Prosthetic & Orthotic Dealers 88 Hotels & Motels 19 Durable Medical Supplies 89 Certified RN Practitioners 21 Urology 91 Electronic Billing 23 Attendant Care & Housekeeping 92 Billing Services 24 Physical & Occ. Therapies 93 Allergy & Immunology 25 Pulmonary Medicine 94 Retraining Supplies 26 Otolaryngology 97 Vehicle Modification 27 Medical Investigation 98 Attorney 28 Funeral Expense 103 Cardiovascular & Thoracic Surgery 29 Emergency & Air Transportation 104 Audiology Services 30 Non-emergency Transportation 105 Occupational Medicine 31 Podiatry Services 106 Infectious Disease 32 Anesthesia 107 Hospice Care 33 Home Health Agencies 108 Speech Therapy 35 Gastroenterology & Endocrinology 109 Optical Dealers 36 Rehab. Centers 110 Claimant 37 Osteopathic Medicine 111 Correspondence Only 38 Laboratory & Pathology Services 112 Private Duty RN 39 Skilled, Cust., and Other Ex. Care 113 Private Duty LPN 40 Occupational Pneumoconiosis CA 114 Third Party Administrators (TPA) 42 Neurology 115 Multidisciplinary Pain Man. Program 43 Physiatry & Rehab. Medicine 116 Temporary Professional Placement American LegalNet, Inc. www.FormsWorkflow.com PRIMARY VENDOR'S SIGNATURE MUST BE MADE BY AN OFFICER, CEO OR CFO OF BUSINESS IF NOT A SOLE PROPRIETOR. Primary Vendor: Authorized Name: Title: Signature: Date: Associate Vendor: Authorized Name: Title: Signature: Date: I/We hereby swear or affirm that to the best of my/our knowledge and belief these statements and representations are true and accurate. I/We accept the provisions of the WV Workers' Compensation Act and the Rules promulgated thereunder, as amended. I/We am/are aware that I/we must timely notify BrickStreet Insurance in writing of any changes in my/our operation. Changes include but are not limited to, change in business type, location, ownership, covered/non-covered status of individual owners, partners in a partnership, corporate/executive officers of a corporation or association, and the status of the business as described in this application. * Please attach copy of most-commonly billed codes and fees. * Failure to provide the information requested will result in delayed registration and/or denial of payment. * West Virginia state providers must be in good standing with BrickStreet Insurance. * If a business license/vendor permit is not required in your state, a letter of explanation and exemption or a copy of the state law or guideline granting your exemption must accompany this application. American LegalNet, Inc. www.FormsWorkflow.com