Get Oh Bwc Medco-12 2023-2025

The OH BWC MEDCO-12 form is essential for requesting changes to provider information. This guide provides clear instructions to help you navigate the form accurately and efficiently.

Follow the steps to complete the OH BWC MEDCO-12 form online.

1. Click ‘Get Form’ button to access the MEDCO-12 form and open it in the online editor.
2. Determine if you are updating an individual provider number or a business/organizational provider number. Complete a separate form for each provider number that needs to be updated.
3. If you have a new tax ID and no change of ownership has occurred, fill out this form and submit a new W-9 form for your records. Provide the date the former number became invalid and the date the new number became effective.
4. Select the record(s) you wish to update by checking the appropriate boxes for 'Individual provider name' or 'Business name.'
5. Provide the necessary identification information: either your SSN or NPI for individuals, or Tax ID or NPI for businesses.
6. If applicable, indicate any changes being requested such as a new practice location, adding an additional location, removing a location, or other changes.
7. Fill in the new information, including the practice address, city, state, ZIP code, telephone, fax, and email address.
8. If different, indicate the reimbursement address and correspondence address, including any suite or floor details.
9. Add the applicant or authorized personnel's signature, title, printed name, and date.
10. Provide your contact information, including name, phone number, and email.
11. Once all sections are completed, save your changes and either download, print, or share the form as necessary.

Complete the OH BWC MEDCO-12 form online to ensure your provider information is accurately updated.