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Enrollment Forms

ACCEPTABLE SIGNATURES ON BTT DOCS 6-8-21 CFO Payee Agreement -- FILLABLE Contact Hours Documentation Form -- FILLABLE WVBTT CFO Enrollment Application Revised 7-1-24 WV Birth to Three National Provider Identification Number Chart 2024 ParentSCstatement -- FILLABLE Practitioner Assurance -- FILLABLE Practitioner Supervisor Documentation -- FILLABLE Rider A -- FILLABLE Rider B -- FILLABLE Enrolled Professional Confidentiality Statement ISC SC and Direct Service Practitoners -- FILLABLE WVBTT_Enrollment_Checklist_Initial_and_Annual_Requirements_ Revised 7-10-24 Enrollment Checklist Second Annual and Ongoing Requirements for All Enrollees -- FILLABLE Criminal Background Check Entry Level Qualifications -- Revised on 11/17/2021 W-9 Birth to Three Direct Deposit Setup Birth to Three Direct Deposit Change Birth to Three Direct Deposit Cancel Birth To Three Core Knowledge and Competencies CKC Crosswalk Chart

Billing Information

WVBTT Billing Manual Services and Rates (PDF) Services and Rates (CSV) Application to Override Denied Claim -- FILLABLE Application for Claim Correction -- FILLABLE

Online Access Forms

Recommended Browsers ISC Online Access Application OSC Online Access Application Practitioner Online Access Application

Electronic Billing Information

278 Authorization Response Companion Guide 835 Remittance Advice Companion Guide 837P Claims Transaction Companion Guide Trading Partner Agreement EDI Testing Procedures

How To Get a Free Email Account