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

FORM 9767.17.5 (PART B) - DWC PETITION FOR SUSPENSION OR REVOCATION OF A MEDICAL PROVIDER NETWORK. This is the official response form that an MPN must complete after receiving a petition requesting suspension or revocation of its approval. The form collects identification information for the petitioner, the MPN, and the MPN’s authorized individual, and requires the network to state in detail why the petition should not be granted. The MPN must provide supporting documentation and file the response within 30 days of service, along with a proof of service showing that copies were mailed to both the petitioner and the Administrative Director. The authorized individual must sign the form under penalty of perjury. www.FormsWorkflow.com