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

DWC PETITION FOR SUSPENSION OR REVOCATION OF A MEDICAL PROVIDER NETWORK FORM 9767.17.5 (PART A) Petitioner to complete all required fields and state the reasons for this Petition with sufficient details below First Name Last Name Phone Number Petitioner E-mail City Mailing Address In what capacity are you filing this petition (Check one): If you selected "Other," please explain: Injured Worker State Zip Code Representative Other MPN Information MPN Name MPN Applicant Name MPN Contact Information MPN Identification No. MPN Contact First Name MPN Contact Last Name MPN Contact E-mail MPN Contact Phone Basis for Petition (Select one) The MPN Applicant does not meet eligibility requirements to have an MPN The MPN has systematically failed to meet MPN access standards pursuant to section 9767.5 on more than one occasion in at least two specific locations within the MPN geographic service area. This failure resulted in a worker being unable to obtain necessary treatment after the MPN has had a reasonable opportunity to remedy the access failure for each occasion and location. State Reasons for Petition (additional pages and documents may be attached): Verification I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Executed at City By: Name of Petitioner Signature of Petitioner Page 1 of 2 DWC Form 9767.17.5 (A) (Rev. 8/2014) American LegalNet, Inc. www.FormsWorkFlow.com , California on (MM/DD/YYYY) DWC PETITION FOR SUSPENSION OR REVOCATION OF A MEDICAL PROVIDER NETWORK FORM 9767.17.5 (PART A) NOTICE TO PETITIONER: You must attach a Proof of Service by Mail indicating that Part A (DWC Petition for Suspension or Revocation of a Medical Provider Network) and Part B (MPN Response to DWC Petition for Suspension or Revocation of a Medical Provider Network) of this form with all supporting evidence were mailed to the Administrative Director and a copy sent to the MPN's authorized individual. NOTICE TO MEDICAL PROVIDER NETWORK: Pursuant to section 9767.17(d) of title 8 of the California Code of Regulations, you may file with the Administrative Director a response to this petition within 30 days from the date the petition was served on you. Your response must be submitted using the MPN Response to DWC Petition for Suspension or Revocation of a Medical Provider Network Form 9767.17.5 (Part B), which is contained in pages 3 of this form. Page 2 of 2 DWC Form 9767.17.5 (A) (Rev. 8/2014) American LegalNet, Inc. www.FormsWorkFlow.com