Fillable Nwc Notice Of Medical Provider Network Plan Modification Form (Page 2 of 2) in pdf

Nwc Notice Of Medical Provider Network Plan Modification Form Page 2

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Change in MPN Service Area: Provide documentation in compliance with section 9767.5.

Change in continuity of care policy: Provide a copy of the revised written continuity of care policy.

Change in transfer of care policy: Provide a copy of the revised written transfer of care policy.

Change in Economic Profiling policy used by MPN Applicant or any entity contracted with MPN:

Provide a copy of the revised policy or procedure.

Change in how the MPN complies with the access standards: Explain what change has been made and

describe how the MPN still complies with the access standards.

Change in employee notification materials, including a change in MPN contact or Medical Access

Assistants contact information, or a change in provider listing access or MPN website information:

Provide a copy of the revised notification materials.

Change in use of one of the following Deemed Entities: Health Care Organization (HCO), Health Care

Service Plan, Group Disability Insurer, or Taft-Hartley Health and Welfare Trust Fund.

Please state change: From_________________

To__________________

Revision of any plan section(s) required by sections 9767.3(d)(8) or 9767.3(e) resulting from a change of

any MPN administrator(s) listed in the MPN Plan. Please include complete sections revised.

Replacement of entire plan application. Please state why and include entire revised plan.

Update of MPN plan to the current regulations pursuant to section 9767.15. Please include entire updated

plan.

Submit two copies of the completed, signed Notice of MPN Plan Modification and any necessary

documentation 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 9767.8 -- 8/14]

Nwc Notice Of Medical Provider Network Plan Modification Form Page 2

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