For DWC only: MPN Approval Number Date Application Received: / / Notice of Medical Provider Network Plan Modification §9767.8 1. Name of MPN Applicant ______________________________________________________________ 2. Address 3. Tax Identification Number ___________________________ ______-_________________ ___________________________ 4. Type of MPN Applicant Self-Insured Employer Group of Self-Insured Employers Self-Insured Security Fund Joint Powers Authority State Insurer 5. Name of Medical Provider Network(s), if applicable: 6. Date of initial application approval and MPN approval number: _________________________________ 7. Dates of prior plan modifications approvals: _________________________________________ 8 If the medical provider network is 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 9. Name of entity, administrator or other third-party who prepared MPN Application on behalf of MPN applicant (if applicable): _____________________________________ 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 ability, 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 [DWC Mandatory Form – section 9767.8 – May 2007] 1 American LegalNet, Inc. www.FormsWorkflow.com 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. Please explain whether the modification will adversely affect the ability of the MPN to meet the regulatory and statutory MPN requirements. ________________________________________________________________________________________ ________________________________________________________________________________________ Change in Service Area: Provide documentation in compliance with section 9767.5. Change of MPN name: Provide new MPN name. Change of Division Liaison: Provide the name and contact information. Change of 10% or more in the number or specialty of Network Providers since the approval date of the previous MPN Plan application or modification: Provide the name, license number, and location of each physician by specialty type or name provider, if other than physician. Change of 25% or more in the number of covered employees since the approval date of the previous MPN Plan application or modification. 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 f the revised written transfer of care policy. Change in Economic Profiling: 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 of employee notification materials: Provide a copy of the revised notification materials. Other (please describe): Attach documentation. Submit an original Notice of MPN Plan Modification with original signature, any necessary documentation, and a copy of the Notice and documents to the Division of Workers’ Compensation. Mailing address: DWC, MPN Application, P.O. Box 71010, Oakland, CA 94612. [DWC Mandatory Form – section 9767.8 – May 2007] 2 American LegalNet, Inc. www.FormsWorkflow.com