Cover Page For Medical Provider Network Application {DWC 9767.4}

For DWC only: MPN Identification Number Date Application Received: Cover Page for Medical Provider Network Application or Plan for Reapproval 1. 2. Legal Name of MPN Applicant_____________________________________________________________ MPN Applicant Address ________________________ ________________________ 4. Eligibility Status of MPN Applicant Self-Insured Employer (including SISF) Insurer (including CIGA, UEBTF) State 5. 6. Group of Self-Insured Employers Joint Powers Authority Entity that provides physician network services 3. Tax Identification Number __ __ - __ __ __ __ __ __ __ Name of Medical Provider Network_______________________________________________________ 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: _____________________________________________________________________________________ MPN Website Address:__________________________________________________________________ MPN Provider Listing Web Address:_______________________________________________________ 8. 9. 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 American LegalNet, Inc. www.FormsWorkFlow.com 11. Authorized Liaison to DWC: Name Title Organization ______________________________________________________________________________________ Phone Email ______________________________________________________________________________________ Address Fax number Submit two copies of the completed, signed Cover Page for Medical Provider Network Application or Plan for Reapproval and the complete MPN Plan in compact discs or flash drives in word searchable PDF format to the Division of Workers' Compensation. Mailing address: DWC, MPN Application, P.O. Box 71010, Oakland, CA 94612. [DWC Mandatory Form - Section 9767.4 - [08/14] American LegalNet, Inc. www.FormsWorkFlow.com