DWC Petition For Suspension Or Revocation Of Medical Provider Network (Part A) {DWC 9767.17.5}

FORM 9767.17.5 (PART A) - DWC PETITION FOR SUSPENSION OR REVOCATION OF A MEDICAL PROVIDER NETWORK.. This is a California Division of Workers’ Compensation form used by injured workers, representatives, or other qualified parties to request the suspension or revocation of an MPN. The form allows the petitioner to document whether the MPN has repeatedly failed to meet access standards under §9767.5 across multiple locations after having reasonable opportunity to correct the issue, or whether the MPN applicant no longer meets eligibility requirements. Petitioners must provide detailed reasons, supporting evidence, and full MPN contact information. The form must be signed under penalty of perjury and served with accompanying materials on both the Administrative Director and the MPN’s authorized individual, along with proof of service. www.FormsWorkflow.com