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Cover Page For Medical Provider Network Application DWC 9767.4 - California
| Cover Page For Medical Provider Network Application Form. This is a California form and can be used in General Workers Comp . |
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For DWC only: MPN Approval Number Date Application Received: / / Cover Page for Medical Provider Network Application 1. Name of MPN Applicant ______________________________________________________________ 2. Address ___________________________ ___________________________ 4. Type of MPN Applicant Self-Insured Employer Self-Insured Security Fund Group of Self-Insured Employers Joint Powers Authority State Insurer 3. Tax Identification Number ______-_________________ 5. Name of Medical Provider Network(s), if applicable: 6. If the medical provider network is one of the following deemed entities, check the appropriate box: Health Care Organization (HCO) Health Care Service Plan Group Disability Insurer Taft-Hartley Health and Welfare Trust Fund 7. Name of entity, administrator or other third-party who prepared MPN Application on behalf of MPN applicant (if applicable): _____________________________________ 8. Signature of authorized individual: "I, the undersigned officer or employee of the MPN Applicant, have read and signed this application and know the contents thereof, and verify that, to the best of my knowledge and ability, the information included in this application is true and correct." ________________________________________________________________________________________ Name of Authorized Individual Title Phone/Email ________________________________________________________________________________________ Signature of Authorized Individual Date Signed 9. Authorized Liaison to DWC: ________________________________________________________________________________________ Name Title Organization Phone/Email ________________________________________________________________________________________ Address Fax number Submit an original Cover Page for Medical Provider Network Application with original signature, an original Application with the information required by Title 8, California Code of Regulations, section 9767.3 and a copy of the Cover Page and Application to the Division of Workers' Compensation. Mailing address: DWC, MPN Application, P.O. Box 71010, Oakland, CA 94612. [DWC Mandatory Form section 9767.4 May 2007] American LegalNet, Inc. www.FormsWorkflow.com
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