Request To Change Provider Information {BWC-3912}

Request to Change Provider Information Instructions · Please print or type. · Return completed form to: Ohio Bureau of Workers' Compensation, Provider Enrollment Unit, P.O. Box 15249, Columbus, OH 43215-0249, or submit by fax: 614-621-1333 30 W. Spring St. Columbus, OH 43215-2256 Questions? Call 1-800-644-6292 to reach BWC's provider relations department Points to review before completing this form · You must determine if you are updating an individual person's provider number or a business/organizational provider number, and complete a separate form for each number to be updated. Submit National Provider Identifier (NPI) verification if applicable. · Business/Organization providers: If you have a new tax ID without change of ownership, complete this form and send us a new W-9 Internal Revenue Service (IRS) form for our records. This form is found at www.irs.gov/pub/irs-pdf/fw9.pdf. Include the date former number became invalid, and the date new number became effective. (Note: no bills will be payable for dates of service after the termination date of the previous provider number). If you are new owners of a tax ID already established in our database, please complete a new provider application (MEDCO-13 or MEDCO-13A) for our files to show authorized agreement signature and ownership information. You do not need to complete this form. Date effective New tax identification number or Social Security number (Attach a copy of the IRS form W-9. This number will be used for IRS purposes). Legal name associated with tax identification number (Must appear as recognized by the IRS) DBA name of group/business or individual provider name Business type Individual Sole proprietor Partnership NPI number (attach Fox Systems, Inc. verification) Current BWC provider number Corporation S Corporation LLC Non-profit Taxonomy code (attach Fox Systems, Inc. verification) Date no longer valid Previous demographic information New information Previous owner name(s) Practice location street address (Indicate the address where you render services, including suite, floor, etc. We will accept a P.O. Box only if you include additional street address information.) City, State, ZIP code E-mail address Telephone Fax ( ) ( ) Reimbursement address (Indicate the address to which we should send all payments, if different from practice address. Include suite, floor etc., street address or P.O. Box.) City, State, ZIP code Correspondence address (Indicate the address to which we should send all correspondence, if different from practice address. Include suite, floor etc., street address or P.O. Box.) City, State, ZIP code New owner name(s) Practice location street address (Indicate the address where you render services, including suite, floor, etc. We will accept a P.O. Box only if you include additional street address information.) City, State, ZIP code Telephone Fax E-mail address ( ) ( ) Reimbursement address (Indicate the address to which we should send all payments, if different from practice address. Include suite, floor etc., street address or P.O. Box.) City, State, ZIP code Correspondence address (Indicate the address to which we should send all correspondence, if different from practice address. Include suite, floor etc., street address or P.O. Box.) City, State, ZIP code Applicant or authorized personnel signature (Required) Reimbursement change information requires provider's signature Please print or type name Title Date BWC-3912 (Rev. 1/03/2013) MEDCO-12 www.FormsWorkFlow.com