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DWC Form 9767.16.5 DWC Medical Provider Network Complaint Form - California
What Is DWC Form 9767.16.5?
This is a legal form that was released by the California Department of Industrial Relations - Division of Workers' Compensation - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.
FAQ
Q: What is DWC Form 9767.16.5?
A: DWC Form 9767.16.5 is the DWC Medical Provider Network Complaint Form.
Q: What is the purpose of the DWC Medical Provider Network Complaint Form?
A: The purpose of this form is to submit a complaint about the Medical Provider Network (MPN) in California.
Q: Who can use the DWC Medical Provider Network Complaint Form?
A: Anyone who has a complaint about the Medical Provider Network (MPN) in California can use this form.
Q: How do I submit the DWC Medical Provider Network Complaint Form?
A: You can submit the completed form by mail or fax to the California Division of Workers' Compensation (DWC).
Form Details:
- Released on August 1, 2014;
- The latest edition provided by the California Department of Industrial Relations - Division of Workers' Compensation;
- Easy to use and ready to print;
- Quick to customize;
- Compatible with most PDF-viewing applications;
- Fill out the form in our online filing application.
Download a fillable version of DWC Form 9767.16.5 by clicking the link below or browse more documents and templates provided by the California Department of Industrial Relations - Division of Workers' Compensation.
