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DWC Form 9767.17.5 (A) Part A DWC Petition for Suspension or Revocation of a Medical Provider Network - California
What Is DWC Form 9767.17.5 (A) Part A?
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 9767.17.5 (A)?
A: DWC Form 9767.17.5 (A) is the Petition for Suspension or Revocation of a Medical Provider Network (MPN) in California.
Q: What is the purpose of DWC Form 9767.17.5 (A)?
A: The purpose of DWC Form 9767.17.5 (A) is to request the suspension or revocation of a Medical Provider Network (MPN) in California.
Q: Who can use DWC Form 9767.17.5 (A)?
A: DWC Form 9767.17.5 (A) can be used by any party that wants to request the suspension or revocation of a Medical Provider Network (MPN) in California.
Q: Do I need to fill out DWC Form 9767.17.5 (A) if I want to suspend or revoke a Medical Provider Network (MPN) in California?
A: Yes, you need to fill out DWC Form 9767.17.5 (A) to officially request the suspension or revocation of a Medical Provider Network (MPN) in California.
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 9767.17.5 (A) Part A by clicking the link below or browse more documents and templates provided by the California Department of Industrial Relations - Division of Workers' Compensation.
Download DWC Form 9767.17.5 (A) Part A DWC Petition for Suspension or Revocation of a Medical Provider Network - California
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