DWC Medical Provider Network Complaint Form 9767.16.5 Person filing compliant (Completion of these fields is required) First Name Mailing Address Person filing the complaint is (Check one): Last Name City Injured worker Attorney E-mail Address State Provider Phone Number Zip Code Other Nature of the Complaint (Check all that apply and provide sufficient details of the descriptions below) Cannot access MPN website provider listing Unable to contact Medical Access assistant and/ or MPN contact Inaccurate MPN listing Employer Name MPN Contact First Name MPN Name MPN Contact Last Name MPN Contact E-mail MPN notice not provided Physician or specialist not available in the MPN Other MPN Identification No. MPN Contact Phone Yes No Date of Initial Written Complaint to MPN (MM/DD/YYYY) Imminent Threat to an Injured worker? Provide a brief description of the complaint (Attach additional pages as needed) 1. Describe or state the specific sections of the Labor Code or the MPN regulations violated: 2. State when the violation occurred and whether you believe the violation is still occurring: 3. Describe specifically what attempts you have made with the MPN to address the violation: 4. Describe, what, if any. impact there has been on an injured worker because of the violation: 5. What result are you seeking because of the alleged violation: Instructions for Formal Complaint Submission to DWC Serve the MPN Contact listed above with a copy of this completed form and all supporting evidence; and submit this completed form with all supporting evidence and proof of service on the MPN Contact to: DWC-MPN Complaints, P.O. Box 71010, Oakland, CA 94612 DWC Form 9767.16.5 (Rev 8/2014) American LegalNet, Inc. www.FormsWorkFlow.com