Application For Provider Enrollment And Certification {BWC-3913}

BWC-3913 - APPLICATION FOR PROVIDER ENROLLMENT AND CERTIFICATION. This form is issued by the Bureau of Workers' Compensation (BWC) in Ohio. The first step to becoming BWC certified is to complete the Application for Provider Enrollment and Certification (MEDCO-13). The form collects essential information about the provider, including their personal and business details, qualifications, licenses, and certifications. Providers are required to complete this form accurately and attach relevant documents such as licenses, certifications, and accreditation documents. The form includes questions about the provider's background, including any legal or disciplinary issues, and requires the provider to explain any affirmative answers. By signing the application, the provider agrees to abide by Ohio Revised Code and BWC rules, accept and adhere to billing and reimbursement policies, maintain adequate records, and comply with confidentiality regulations. Providers are also required to maintain professional liability insurance and agree not to bill BWC for missed appointments. www.FormsWorkflow.com