Request To Change Provider Information {BWC-3912}

BWC-3912 - REQUEST TO CHANGE PROVIDER INFORMATION. This form from the Bureau of Workers' Compensation (BWC) is used by individual or organizational healthcare providers to update their information in BWC's provider database. This form is necessary when making changes such as provider name updates, address modifications, tax ID changes, practice closures, retirements, or terminations of provider relationships. It is also used to add or remove practice locations and to update reimbursement or correspondence addresses. Depending on the nature of the change, providers may be required to submit additional documentation, such as a W-9 form or legal proof of name change. The form ensures BWC has accurate, up-to-date provider information for billing, reimbursement, and communication purposes. Providers must submit the form via email, fax, mail, or through BWC’s online provider portal. MEDCO-12. www.FormsWorkflow.com