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New Employers may choose an MCO immediately.

Employers who currently have an MCO may change to a different MCO only during Ohio Bureau of Workers' Compansation (BWC) designated Open Enrollement periods.

To choose Health Mangement Solutions, simply fill out the form below and submit it to Health Management Solutions. If you want further information on the advantages of choosing Health Management Solutions, call Cyndi Britton toll free ar 1-888-202-3515, or email at CyndiB@hmssolutions.com

Simply fill out the form below and submit it to Health Management Solutions.

Employer Policy Number:
Company Name:
DBA Name (If Applicable):
Contact Name:
Phone Number:
Fax Number:
E-mail Adress:
Number of Employees:
County of Operation:
Name of MCO Selected:
MCO Number:

EMPLOYER'S RIGHT TO SELECT
	Employer Title: Date:

EMPLOYER'S RIGHT TO SELECT