For DWC only: MPN Approval Number Date Notice 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 MPN, 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 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 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 Organization Phone/Email ____________________________________________________________________________________________ Signature of Authorized Individual Date Signed 11. Authorized Liaison to DWC: ____________________________________________________________________________________________ Name Title Organization Phone/Email ____________________________________________________________________________________________ Address Fax number 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 or MPN Applicant name: Provide new name and plan sections affected by the change. Change of Division Liaison or Authorized Individual: 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 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 of the revised written transfer of care policy. Change in Economic Profiling policy used by MPN Applicant or any entity contracted with MPN: 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, including a change in MPN contact information, or a change in provider listing access or website information: Provide a copy of the revised notification materials. Change in use of one of the following Deemed Entities: Health Care Organization (HCO), Health Care Service Plan, Group Disability Insurer, or Taft-Hartley Health and Welfare Trust Fund. Please state change: From _________________ To ________________ Revision of any plan section(s) required by sections 9767.3(d)(8) or 9767.3(e) resulting from a change of any MPN administrator(s) listed in the MPN Plan. Please include complete sections revised. Replacement of entire plan application. Please state why and include entire revised plan. Update of MPN plan to the permanent regulations pursuant to section 9767.15. Please include entire updated plan. 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 -- June 2010] American LegalNet, Inc. www.FormsWorkFlow.com