Nwc Notice Of Medical Provider Network Plan Modification Form
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For DWC only: MPN Identification Number
Date Notice Received:
Notice of Medical Provider Network Plan Modification §9767.8
1.
Legal Name of MPN Applicant_____________________________________________________________
2.
Name of MPN and MPN Identification Number________________________________________________
3.
MPN Applicant Address
4. Tax Identification Number____--_______________
________________________
________________________
Signature of authorized individual: “I, the undersigned officer or employee of the MPN Applicant, have
5.
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 modification is true and correct.”
______________________________________________________________________________________
Name of Authorized Individual
Title
Organization
______________________________________________________________________________________
Phone
Email
______________________________________________________________________________________
Signature of Authorized Individual
Date Signed
6.
Authorized Liaison to DWC:
______________________________________________________________________________________
Name
Title
Organization
______________________________________________________________________________________
Phone
Email
______________________________________________________________________________________
Address
Fax number
7.
Please give a short summary of the proposed modifications in the space provided below and place a check
mark against the box that reflects the proposed modification.
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Change of MPN name or MPN Applicant name: Provide new name and plan sections affected by the
change within fifteen (15) business days of the change.
Change in MPN Applicant eligibility status. Provide date of change in eligibility and reason for change.
Must file within fifteen (15) business days of change in status.
Change of Division Liaison or Authorized Individual: Provide the name and contact information within
fifteen (15) business days of change.
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