California Code of Regulations › Title 8 - Industrial Relations › Division 1 - Department of Industrial Relations › Chapter 4.5 - Division of Workers' Compensation › Subchapter 1 - Administrative Director-Administrative Rules › Article 3.5 - Medical Provider Network › Section 9767.4 - Cover Page for Medical Provider Network Application or Plan for Reapproval

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
For DWC only: MPN Identification
								Number
Date Application Received: / /
Cover Page for Medical Provider Network
								Application or Plan for Reapproval
1. Legal Name of MPN Applicant
								___________________________
2. MPN Applicant Address
3. Tax Identification Number
___________________________
__ __--__ __ __
								__ __ __ __
___________________________
4.
					 Eligibility Status of MPN Applicant
[] Self-Insured Employer (including SISF) [] Insurer
						(including CIGA, UEBTF) [] Group of Self-Insured Employers
[] Joint Powers Authority [] State [] Entity that
						provides physician network services
___________________________
5. Name of Medical Provider
					 Network:
6. If the medical provider
					 network is using 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. Is this a plan for
					 reapproval? [] Yes [] No If Yes, include date of last MPN approval and MPN
					 Identification Number:
____________________________________________________________
8. MPN Website Address:
___________________________
9. MPN Provider Listing Web Address::
___________________________
10. 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 belief, the information included in this application is true
					 and correct."
___________________________
Name of Authorized Individual
Title
___________________________
Phone
Email
___________________________
Signature of Authorized Individual
Date
								Signed
11. Authorized Liaison to DWC:
___________________________
Name
Title
Organization
___________________________
Phone
Email
___________________________
Address
Fax number
1. New
						section filed 11-1-2004 as an emergency; operative 11-1-2004 (Register 2004,
						No. 45). A Certificate of Compliance must be transmitted to OAL by 3-1-2005 or
						emergency language will be repealed by operation of law on the following
						day.
2. New section refiled 2-28-2005 as an emergency; operative
						3-1-2005 (Register 2005, No. 9). A Certificate of Compliance must be
						transmitted to OAL by 6-29-2005 or emergency language will be repealed by
						operation of law on the following day.
3. New section refiled
						6-20-2005 as an emergency; operative 6-29-2005 (Register 2005, No. 25). A
						Certificate of Compliance must be transmitted to OAL by 10-27-2005 or emergency
						language will be repealed by operation of law on the following
						day.
4. Certificate of Compliance as to 6-20-2005 order, including
						amendment of section and NOTE, transmitted to OAL 7-29-2005 and filed 9-9-2005
						(Register 2005, No. 36).
5. Change without regulatory effect
						amending section filed 5-23-2007 pursuant to section
						100, title 1, California Code of
						Regulations (Register 2007, No. 21).
6. Amendment of section heading
						and section (DWC Mandatory Form -- Section
						9767.4) and amendment of NOTE filed
						8-27-2014; operative 8-27-2014 pursuant to Government Code section
						11343.4(b)(3)
						(Register 2014, No. 35).
Note: Authority cited: Sections
						  133 and
						  4616(h),
						  Labor Code. Reference: Sections
						  3700,
						  3743,
						  4616,
						  4616.5 and
						  4616.7, Labor
						  Code.