Medco change of ownership form: Fill out & sign online

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Click ‘Get Form’ to open the medco change of ownership form in the editor.
Begin by determining whether you are updating an individual or business provider number. Complete a separate form for each number that needs updating.
Fill in the 'New tax identification number' or Social Security number, ensuring to attach a copy of the IRS W-9 form for verification.
Provide the legal name associated with the tax ID and any DBA (Doing Business As) names, along with your business type (e.g., Individual, Corporation).
Complete the sections for previous demographic information, including your current BWC provider number and previous owner names.
Enter the practice location address where services are rendered, along with contact details such as telephone and email addresses.
Finally, ensure that an authorized personnel signature is included at the bottom of the form before submitting it via mail or fax.

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Versions	Form popularity	Fillable & printable
2023	4.3 Satisfied (39 Votes)
2013	4 Satisfied (45 Votes)

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