Application For Provider Enrollment Non Certification {BWC-3915}

APPLICATION FOR PROVIDER ENROLLMENT-NON CERTIFICATION. Providers who wish to enroll with BWC but do not have to be BWC certified should complete this form. Important: If your provider type is not listed in Section 1, you must complete the MEDCO-13. All applications are reviewed to ensure providers meet the minimum enrollment criteria. Providers must meet all licensing, certification, or accreditation requirements necessary to provide services. We base minimum credentials for providers on provider type. Note to pharmacy providers: Pharmacies must apply directly with BWC’s current pharmacy benefits manager (PBM) to receive a BWC provider number. Our current PBM is Change Healthcare. You may email BWCHelpDesk@ changehealthcare.com or call 888-292-5229 to request enrollment for the Ohio Bureau of Workers’ Compensation. Ohio pharmacies must have Ohio workers’ compensation coverage. www.FormsWorkflow.com