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 | |
___________________________ | __ __--__ __ __ __ __ __ __ |
___________________________ |
[] Self-Insured Employer (including SISF) [] Insurer (including CIGA, UEBTF) [] Group of Self-Insured Employers
[] Joint Powers Authority [] State [] Entity that provides physician network services
___________________________
[] Health Care Organization (HCO)
[] Health Care Service Plan
[] Group Disability Insurer
[] Taft-Hartley Health and Welfare Trust Fund
____________________________________________________________
___________________________
___________________________
___________________________ | |
Name of Authorized Individual | Title |
___________________________ | |
Phone |
___________________________ | |
Signature of Authorized Individual | Date Signed |
___________________________ | |||
Name | Title | Organization | |
___________________________ | |||
Phone | |||
___________________________ | |||
Address | Fax number |
Cal. Code Regs. Tit. 8, § 9767.4
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 A Certificate of Compliance must be transmitted to OAL by 6-29-2005 or emergency language will be repealed by operation of law on the following day.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 A Certificate of Compliance must be transmitted to OAL by 10-27-2005 or emergency language will be repealed by operation of law on the following day.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.
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).
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).
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).