Application Requirements

All providers should complete an application to be recognized by BrickStreet Insurance, and to receive compensation for treating workers’ compensation patients. To complete the application, you will need the following information:

• Provider Application
• Associate information (if applicable)
• Completed Provider Agreement
• One of the following showing you are able to do business in West Virginia:
  Business license
  Vendor permit
  Articles of Incorporation
  Accreditation
  Professional license
  DEA certificate
  American Board Certification
  Malpractice/Liability insurance certificate
  Completed W-9 with signature
  Explanations regarding restrictions, suspensions, loss of privileges, etc. (if applicable)