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Get Workers Compenstion Provider Form Omb Number 1240 0021
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How to fill out the Workers Compensation Provider Form OMB Number 1240 0021 online
This guide will assist you in completing the Workers Compensation Provider Form OMB Number 1240 0021 online. By following these detailed steps, you can ensure your submission is accurate and complete.
Follow the steps to successfully fill out the form.
- Click the ‘Get Form’ button to obtain the form and open it in your chosen editor.
- Determine if you are applying for a new enrollment or updating an existing record by selecting the appropriate option in Block 1.
- If you are updating, enter your Provider Number or Employer Identification Number (EIN) in Block 1a.
- Indicate the earliest date you treated a participant in any OWCP program in Block 2.
- Fill out your practice name in Block 3 and your practice's physical address, city, state, and zip code in Blocks 4, 5, 6, and 7.
- Enter your practice telephone number in Block 8 and FAX number, if applicable, in Block 9.
- Provide your practice email address in Block 9a, if applicable.
- Select your type of practice in Block 10, choosing either individual, facility, or group.
- Complete Block 11 with your Provider Type Code and Description based on your practice type.
- Fill in your Tax ID number in Block 12.
- Complete the relevant hospital information in Blocks 13a, 13b, and 13c if you checked the hospital option.
- For individual practices, fill in the name and license information in Block 14, including current license expiration date.
- If applicable, provide your United Mine Workers' of America Number in Block 15.
- If your billing address is the same as your practice address, write 'same' in Block 16a; otherwise, fill in the address, city, state, and zip in Blocks 16b, 16c, and 16d.
- Indicate completion of ACH Vendor Payment or Electronic Funds Transfer form in Block 17.
- In Block 18, indicate your interest in electronic billing by checking the appropriate box.
- Ensure you sign and date the form before submission.
- Save your changes. You can download, print, or share the completed form as needed.
Complete your documents online to ensure efficient processing.
To obtain a Workers' Compensation Account (WCA) number, you may need to complete specific registration steps through your state’s workers’ compensation board. This typically involves providing details about your business and the workers covered under your policy. Obtaining this number is vital, especially when submitting claims with the Workers Compensation Provider Form Omb Number 1240 0021.
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