West Virginia > Workers Comp
Application For Provider Registration BI-210apr - West Virginia
| Application For Provider Registration Form. This is a West Virginia form and can be used in Workers Comp . |
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BI-210apr Application for Provider Registration Effective date of service with BrickStreet Insurance: Business Name: Tax ID: Contact Name: USE BLACK INK ATTACH A COMPLETED AND SIGNED W-9 FORM. 01/06 Return completed form to: BrickStreet Mutual Insurance Provider Registration Unit P.O. Box 4228 Charleston WV 25364 Contact Phone: Physical Location City Remittance Address City Correspondence Address City Phone For EFT: Account Number Is this one -time service? For West Virginia businesses--BrickStreet Policy No.: State Fax Routing Number Date(s) of service Zip State Zip State Zip SOLE PROPRIETOR ONLY I elected not to have workers' compensation employer coverage. Yes No Associate's Name: SSN: License No .: (Please include current copy of professional license.) UPIN: Title: State of Licensure: Expiration Date: DEA No.: (Please include current copy of DEA cert.) ASSOCIATE INFORMATION (IF APPLICABLE) Has your professional l icense ever been restricted or revoked? Have your hospital privileges ever been restricted or revoked? Yes Yes No No 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 No (If the answer to any of the above questions is yes, you must attach an explanation.) Board certified? Board Name Yes No Certification Date: (Please include copy of board certification) Specialty Expiration Date: BrickStreet Mutual Insurance P.O. Box 4228 Charleston, WV 25364 American LegalNet, Inc. www.USCourtForms.com BI-210aprr Practice Type: Provider Specialty: Page 2 Code 1 2 3 4 5 6 7 8 VENDO R INFORMATION (PLEASE USE LISTING OF PRACTICE TYPES AND SPECIALTY CODES ) Practice Type Individual Practice Partnership Corporation Group Practice Pharmacy Chain Clinic Nonprofit Organization Limited Liability Company Code 1 2 3 4 5 6 7 8 9 10 11 12 13 14 16 17 18 19 21 23 24 25 26 27 28 29 30 31 32 33 35 36 37 38 39 40 42 43 Provider Specialty Type Acute Hospitals Pharmacy Outpatient Centers and Clinics General Surgery Psychiatry & Psychology Orthopedics & Orthopedic Surgery General & Family Practice Ophthalmology Dermatology Internal Medicine Plastic Surgery Cardiology Dentistry & Dental Surgery Radiology Chiropractic Services Rehab. Services Prosthetic & Orthotic Dealers Durable Medical Supplies Urology Attendant Care & Housekeeping Physical & Occ. Therapies Pulmonary Medicine Otolaryngology Medical Investigation Funeral Expense Emergency & Air Transportation Non-emergency Transportation Podiatry Services Anesthesia Home Health Agencies Gastroenterology & Endocrinology Rehab. Centers Osteopathic Medicine Laboratory & Pathology Services Skilled, Cust., and Other Ex. Care Occupational Pneumoconiosis CA Neurology Physiatry & Rehab. Medicine Code 44 48 51 52 54 55 68 71 72 74 75 76 80 82 83 86 88 89 91 92 93 94 97 98 103 104 105 106 107 108 109 110 111 112 113 114 115 116 Provider Specialty Type Union Representatives Neurological Surgery Optometry Chronic Pain Facilities Household Modification Employer Vocational Retraining Misc. *Must explain specia lty Obstetrics & Gynecology Emergency & Critical Care Rheumatology Hearing Aid Dealers Court Reporting Hematology & Oncology Widow and Widower Psychiatric Hospitals Hotels & Motels Certified RN Practitioners Electronic Billing Billing Services Allergy & Immunology Retraining Supplies Vehicle Modification Attorney Cardiovascular & Thoracic Surgery Audiology Services Occupational Medicine Infectious Disease Hospice Care Speech Therapy Optical Dealers Claimant Correspondence Only Private Duty RN Private Duty LPN Third Party Administrators (TPA) Multidisciplinary Pain Man. Program Temporary Professional Placement American LegalNet, Inc. www.USCourtForms.com BI-210aprr Primary Vendor Authorized Name: Title: Page 3 Signature: Date: PRIMARY VENDOR'S SIGNATURE MUST BE MADE BY AN OFFICER, CEO OR CFO OF BUSINESS IF NOT A SO LE PROPRIETOR. 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.USCourtForms.com
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