Notice Of Medical Provider Network Plan Modification 9767.8 {DWC 9767.8}

NOTICE OF MEDICAL PROVIDER NETWORK PLAN MODIFICATION §9767.8.This is a mandatory California Division of Workers’ Compensation form used by MPN applicants to report changes to an approved MPN plan. The form requires identification of the MPN applicant, MPN name and ID, authorized signatory, and DWC liaison information. Applicants must summarize proposed modifications and check the appropriate categories, which include changes to MPN name, applicant eligibility, service area, continuity or transfer-of-care policies, economic profiling policies, access-standards compliance, employee notification materials, use of deemed entities, or administrative roles. Some changes require supporting documentation or full revised plan sections. Completed submissions must be provided in duplicate on searchable electronic media and mailed to the DWC’s MPN Application Unit. www.FormsWorkflow.com