Cover Page For Medical Provider Network Application Or Plan For Reapproval Page 2
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211. Authorized Liaison to DWC:
Name
Title
Organization
______________________________________________________________________________________
Phone
Email
______________________________________________________________________________________
Address
Fax number
Submit two copies of the completed, signed Cover Page for Medical Provider Network Application or Plan for
Reapproval and the complete MPN Plan in compact discs or flash drives in word searchable PDF format to the
Division of Workers’ Compensation. Mailing address: DWC, MPN Application, P.O. Box 71010, Oakland, CA
94612.
[DWC Mandatory Form - Section 9767.4 - [08/14]
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