Cal. Code Regs. tit. 8, § 9767.4 – 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

For DWC only: MPN Identification Number

Date Application Received: / /

Cover Page for Medical Provider Network Application or Plan for Reapproval

Note: Authority cited: Sections 133 and 4616(h), Labor Code. Reference: Sections 3700, 3743, 4616, 4616.5 and 4616.7, Labor Code.

History

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 A Certificate of Compliance must be transmitted to OAL by 3-1-2005 or emergency language will be repealed by operation of law on the following day.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 A Certificate of Compliance must be transmitted to OAL by 6-29-2005 or emergency language will be repealed by operation of law on the following day.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 A Certificate of Compliance must be transmitted to OAL by 10-27-2005 or emergency language will be repealed by operation of law on the following day.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).