DWC Medical Provider Network Complaint Form 9767.16.5
First Name Last Name
Phone Number
E-mail Address
Zip Code
State
City
Mailing Address
Person filing the complaint is (Check one):
Injured worker Attorney Provider Other
Nature of the Complaint (Check all that apply and provide sufficient details of the descriptions below)
MPN notice not provided
Unable to contact Medical Access assistant and/ or MPN contact Physician or specialist not available in the MPN
OtherInaccurate MPN listing
Cannot access MPN website provider listing
Employer Name
MPN Name
MPN Contact PhoneMPN Contact E-mailMPN Contact Last NameMPN Contact First Name
MPN Identification No.
Date of Initial Written Complaint to MPN (MM/DD/YYYY)
Provide a brief description of the complaint (Attach additional pages as needed)
1. Describe or state the specific sections of the Labor Code or the MPN regulations violated:
2. State when the violation occurred and whether you believe the violation is still occurring:
3. Describe specifically what attempts you have made with the MPN to address the violation:
4. Describe, what, if any. impact there has been on an injured worker because of the violation:
5. What result are you seeking because of the alleged violation:
Instructions for Formal Complaint Submission to DWC
Imminent Threat to an Injured worker?
Yes No
Serve the MPN Contact listed above with a copy of this completed form and all supporting evidence; and submit this completed form with all
supporting evidence and proof of service on the MPN Contact to: DWC-MPN Complaints, P.O. Box 71010, Oakland, CA 94612
DWC Form 9767.16.5 (Rev 8/2014)
Person filing compliant (Completion of these fields is required)
