Notice Of Medical Provider Network Plan Modification Section 9767.8 - Division Of Workers' Compensation

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For DWC only: MPN Approval Number
Date Notice Received: / /
Notice of Medical Provider Network Plan Modification §9767.8
1.
Name of MPN Applicant ______________________________________________________________
2.
Address
3. Tax Identification Number
___________________________
______-_________________
___________________________
4.
Type of MPN Applicant
Self-Insured Employer
Group of Self-Insured Employers
Self-Insured Security Fund
Joint Powers Authority
State
Insurer
5.
Name of MPN, if applicable:
6.
Date of initial application approval and MPN approval number: ____________________________________
7.
Dates of prior plan modifications approvals: ____________________________________________________
8.
If the medical provider network is using one of the following deemed entities, check the appropriate box:
Health Care Organization (HCO)
Health Care Service Plan
Group Disability Insurer
Taft-Hartley Health and Welfare Trust Fund
9.
Name of entity, administrator or other third-party who prepared MPN Application on behalf of MPN applicant
(if applicable): _____________________________________
10. Signature of authorized individual: “I, the undersigned officer or employee of the MPN Applicant, have read
and signed this application and know the contents thereof, and verify that, to the best of my knowledge and
ability, the information included in this application is true and correct.”
____________________________________________________________________________________________
Name of Authorized Individual
Title
Organization
Phone/Email
____________________________________________________________________________________________
Signature of Authorized Individual
Date Signed
11. Authorized Liaison to DWC:
____________________________________________________________________________________________
Name
Title
Organization
Phone/Email
____________________________________________________________________________________________
Address
Fax number

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