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Application For Provider Enrollment And Certification BWC-3913 - Ohio
| Application For Provider Enrollment And Certification Form. This is a Ohio form and can be used in Medical Providers Workers Comp . |
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Application for Provider Enrollment and Certification Provider Enrollment and Certification MEDCO-13 The first step to becoming BWC certified is to complete the Application for Provider Enrollment and Certification (MEDCO-13). We review all applications to ensure eligible providers meet the minimum enrollment and certification criteria. Providers must meet all licensing, certification or accreditation requirements necessary to provide services. Minimum credentials for providers are established based on the provider type. Once the certification process is completed, we will include your name on the provider look-up on its Web site, ohiobwc.com. We also will provide your name to the managed care organizations (MCOs) responsible for medically managing BWC's workers' compensation claims. In addition, Provider types 76 (Vocational rehabilitation vocational case management), 87 (Rehabilitation vocational case management intern) and 90 (Ergonomist) must complete the Declaration Regarding Material Assistance/Non-Assistance to a Terrorist Organization (DMA) certification as required by the Ohio Department of Public Safety/Ohio Homeland Security. These provider types must register at the Ohio Business Gateway, http://obg.ohio.gov to certify that the provider does not provide material assistance to any organization on the United States, Department of State's terrorist exclusion list. Failure to complete the certification by these provider types may invalidate their provider application/agreement and/or result in suspension of payment until such time as the certification is completed. Visit us on the Internet at: Have questions? Call 1-800-OHIOBWC, and listen to the options to reach BWC's provider relations department, between 8 a.m. and 5 p.m. weekdays. All provider types are not required to become BWC certified. If you do not find your provider type in Section 1 of the application, please see the Medco-13A form available at ohiobwc.com. ohiobwc.com Completing the MEDCO-13 · Please print or type. · Please complete one application/agreement per federal tax identification number. · List all practice locations (use separate sheet if needed) · Complete a separate application/agreement for each individual member of a group physician practice. · Return the completed application/agreement to: BWC Provider Enrollment P.O. Box 182031 Columbus, OH 43218-2031 Fax 614-621-1333 Important reminders Authorized signature required on each application/agreement. Please include the following with your application/agreement, if applicable: · State licensure or accreditation/certification document copy with number and expiration date; · Board or diplomate certificate, if applicable; · Professional liability insurance (malpractice) coverage sheet, if applicable; · Drug Enforcement Administration registration, if applicable; · Internal Revenue Service form W-9; http://www.irs.gov/pub/irs-pdf/fw9.pdf; · Workers' compensation coverage policy; · National provider ID verification (from Fox Systems, Inc.), if applicable; · Proof of Telemedicine certificate from Medical board or Accupuncture certificate from Chiropractic Board, if applicable. American LegalNet, Inc. www.FormsWorkFlow.com Application for Provider Enrollment and Certification Section 1 Provider type Select the type that best describes you and complete sections requested for that particular type. If you do not find your provider type, see the Medco-13A form available at ohiobwc.com. If you check one of the following, complete sections 2,3,4 and 5 and attach required documents. 04 05 09 14 15 27 28 33 Audiologist state board of speech pathology and audiology license Non-physician acupuncturist applicable state medical board registration Physician (Chiropractor/DC) state chiropractic board license; state board acupuncture certificate if applicable Physician assistant NCCPA certification and certificate of registration from state medical board Dentist (DDS) state dental board license Hearing aid dealer/dispenser state hearing aid dealers and fitters board license Certified shoe retailer Prescription Footwear Association certification Advanced practice nurse (clinical nurse specialist and certified nurse practitioner) ANCC certified equivalent and certificate of authority from state nursing board Massage therapist/massotherapist state medical board license Nurse anesthetist AANA or CRNA certification and certificate of authority from state nursing board Occupational therapist state occupational therapy, physical therapy and athletic trainers board license Optician state optical dispensers board license Optometrist (OD) state board license 65 66 67 68 70 71 72 76 84 88 Physical therapist (LPT) state occupational therapy, physical therapy and athletic trainers board license Physician (DO) state board license state board telemedicine certificate if applicable Physician (MD) state board license state board telemedicine certificate if applicable Athletic trainer license from the state occupational therapy, physical therapy and athletic trainers board Podiatrist (DPM) state board license Prosthetist/orthotist/pedorthist (CO, CP, COP) license from orthotics, prosthetics and pedorthics board Psychologist (PhD) state board license Vocational Rehabilitation Vocational case management ABVE, COHN, CRC, CRRN, CVE, CDMS or CCM credentials Professional counselor (licensed) and social worker (licensed) state counselor and social worker board license Professional clinical counselor (licensed) and independent social worker (licensed) state counselor and social worker board license Speech pathologist state board of speech pathology and audiology license Ergonomist CPE; CHFP, AEP, AHFP, CEA, CSP with ergonomics specialist designation, CIE, CIH, ATP or RET 48 52 57 58 59 89 90 If you check one of the following, complete sections 2, and 5 and attach the required documents. 01 02 03 10 11 16 17 Air ambulance private: license from Ohio Medical Transportation Board; public/government: Medicare participation Ambulance/Ambulette Service private: license from Ohio Medical Transportation Board; public/government: Medicare participation Ambulatory surgical center: Ohio Department of Health license and Medicare participation Clinic drug/alcohol (free standing) state department of alcohol and drug addiction services certification Pain clinic free standing CARF accreditation; hospital based, CARF or Joint Commission
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