DWC PETITION FOR SUSPENSION OR REVOCATION OF A MEDICAL PROVIDER NETWORK FORM 9767.17.5 (PART B) The MPN to complete all required fields and state the reasons why Petition should not be granted below Petitioner's Information First Name Last Name MPN Information MPN Name Date MPN Received Petition (MM/DD/YYYY) Phone Number Petitioner E-mail MPN Applicant Name MPN Identification No. MPN Contact Information MPN Contact First Name MPN Contact Last Name MPN Contact E-mail MPN Contact Phone MPN Authorized Individual Information First Name Last Name E-mail Address Phone Number State reasons why petition should not be granted (additional pages and documents may be attached): Verification I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Executed at City By: Name of Authorized Individual Signature of Authorized Individual NOTICE TO MPN Proof of Service is Required: A proof of service by mail showing a copy of the response has been served on the Petitioner and Administrative Director must be attached and submitted with this form and all supporting documentation within 30 days from the date the petition was served on the MPN. Page 3 of 3 DWC Form 9767.17.5 (B) (Rev. 8/2014) American LegalNet, Inc. www.FormsWorkFlow.com , California on (MM/DD/YYYY)