Cover Page For Medical Provider Network Application Or Plan For Reapproval
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For DWC only: MPN Identification Number
Date Application Received:
Cover Page for Medical Provider Network Application or Plan for Reapproval
1.
Legal Name of MPN Applicant_____________________________________________________________
2.
MPN Applicant Address
3.
Tax Identification Number __ __ - __ __ __ __ __ __ __
________________________
________________________
4.
Eligibility Status of MPN Applicant
Self-Insured Employer (including SISF)
Group of Self-Insured Employers
Insurer (including CIGA, UEBTF)
Joint Powers Authority
State
Entity that provides physician network services
5.
Name of Medical Provider Network_______________________________________________________
6.
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
7.
Is this a plan for reapproval?
Yes
No
If Yes, include date of last MPN approval and MPN
Identification Number:
_____________________________________________________________________________________
8.
MPN Website Address:__________________________________________________________________
9.
MPN Provider Listing Web Address:_______________________________________________________
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 belief, the information included in this application is true and correct.”
_____________________________________________________________________________________
Name of Authorized Individual
Title
_____________________________________________________________________________________
Phone
Email
_____________________________________________________________________________________
Signature of Authorized Individual
Date Signed
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Parent category: Business