DWC Form 9767.8 "Notice of Medical Provider Network Plan Modification" - California

What Is DWC Form 9767.8?

This is a legal form that was released by the California Department of Industrial Relations - Division of Workers' Compensation - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on August 1, 2014;
  • The latest edition provided by the California Department of Industrial Relations - Division of Workers' Compensation;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of DWC Form 9767.8 by clicking the link below or browse more documents and templates provided by the California Department of Industrial Relations - Division of Workers' Compensation.

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Download DWC Form 9767.8 "Notice of Medical Provider Network Plan Modification" - California

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For DWC only: MPN Identification Number
Date Notice Received:
Notice of Medical Provider Network Plan Modification §9767.8
1.
Legal Name of MPN Applicant_____________________________________________________________
2.
Name of MPN and MPN Identification Number________________________________________________
3.
MPN Applicant Address
4. Tax Identification Number____--_______________
________________________
________________________
Signature of authorized individual: “I, the undersigned officer or employee of the MPN Applicant, have
5.
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 modification is true and correct.”
______________________________________________________________________________________
Name of Authorized Individual
Title
Organization
______________________________________________________________________________________
Phone
Email
______________________________________________________________________________________
Signature of Authorized Individual
Date Signed
6.
Authorized Liaison to DWC:
______________________________________________________________________________________
Name
Title
Organization
______________________________________________________________________________________
Phone
Email
______________________________________________________________________________________
Address
Fax number
7.
Please give a short summary of the proposed modifications in the space provided below and place a check
mark against the box that reflects the proposed modification.
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Change of MPN name or MPN Applicant name: Provide new name and plan sections affected by the
change within fifteen (15) business days of the change.
Change in MPN Applicant eligibility status. Provide date of change in eligibility and reason for change.
Must file within fifteen (15) business days of change in status.
Change of Division Liaison or Authorized Individual: Provide the name and contact information within
fifteen (15) business days of change.
PRINT CLEAR
For DWC only: MPN Identification Number
Date Notice Received:
Notice of Medical Provider Network Plan Modification §9767.8
1.
Legal Name of MPN Applicant_____________________________________________________________
2.
Name of MPN and MPN Identification Number________________________________________________
3.
MPN Applicant Address
4. Tax Identification Number____--_______________
________________________
________________________
Signature of authorized individual: “I, the undersigned officer or employee of the MPN Applicant, have
5.
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 modification is true and correct.”
______________________________________________________________________________________
Name of Authorized Individual
Title
Organization
______________________________________________________________________________________
Phone
Email
______________________________________________________________________________________
Signature of Authorized Individual
Date Signed
6.
Authorized Liaison to DWC:
______________________________________________________________________________________
Name
Title
Organization
______________________________________________________________________________________
Phone
Email
______________________________________________________________________________________
Address
Fax number
7.
Please give a short summary of the proposed modifications in the space provided below and place a check
mark against the box that reflects the proposed modification.
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Change of MPN name or MPN Applicant name: Provide new name and plan sections affected by the
change within fifteen (15) business days of the change.
Change in MPN Applicant eligibility status. Provide date of change in eligibility and reason for change.
Must file within fifteen (15) business days of change in status.
Change of Division Liaison or Authorized Individual: Provide the name and contact information within
fifteen (15) business days of change.
Change in MPN Service Area: Provide documentation in compliance with section 9767.5.
Change in continuity of care policy: Provide a copy of the revised written continuity of care policy.
Change in transfer of care policy: Provide a copy of the revised written transfer of care policy.
Change in Economic Profiling policy used by MPN Applicant or any entity contracted with MPN:
Provide a copy of the revised policy or procedure.
Change in how the MPN complies with the access standards: Explain what change has been made and
describe how the MPN still complies with the access standards.
Change in employee notification materials, including a change in MPN contact or Medical Access
Assistants contact information, or a change in provider listing access or MPN website information:
Provide a copy of the revised notification materials.
Change in use of one of the following Deemed Entities: Health Care Organization (HCO), Health Care
Service Plan, Group Disability Insurer, or Taft-Hartley Health and Welfare Trust Fund.
Please state change: From_________________
To__________________
Revision of any plan section(s) required by sections 9767.3(d)(8) or 9767.3(e) resulting from a change of
any MPN administrator(s) listed in the MPN Plan. Please include complete sections revised.
Replacement of entire plan application. Please state why and include entire revised plan.
Update of MPN plan to the current regulations pursuant to section 9767.15. Please include entire updated
plan.
Submit two copies of the completed, signed Notice of MPN Plan Modification and any necessary
documentation 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 9767.8 -- 8/14]
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