Cover Page For Medical Provider Network Application {DWC 9767.4}

COVER PAGE FOR MEDICAL PROVIDER NETWORK APPLICATION OR PLAN FOR REAPPROVAL. This is a mandatory California Division of Workers’ Compensation form used by insurers, self-insured employers, joint powers authorities, and other eligible entities to submit a new Medical Provider Network (MPN) application or request reapproval of an existing network. The form collects key administrative details, including the applicant’s legal name, address, tax ID, eligibility status, network name, deemed entity type (such as HCO or health care service plan), and website information. Applicants must also provide reapproval data when applicable and designate both an authorized signatory and an official liaison to the DWC. Completed forms must be submitted in duplicate along with the full MPN plan in searchable PDF format on digital media. www.FormsWorkflow.com