Examples of MPN Applicant in a sentence
Type of MPN Applicant Self-Insured Employer Group of Self-Insured Employers Self-Insured Security Fund Joint Powers Authority State Insurer 5.
Tax Identification Number -- __ 4.5. Type of MPN Applicant Self-Insured Employer Insurer Group of Self-Insured Employers Self-Insured Security Fund Joint Powers Authority State Insurer Entity that provides physician network services 5.
Tax Identification Number -- _ 4.Type of Eligibility Status of MPN Applicant □ Self-Insured Employer (including SISF) □ Insurer (including CIGA, SISFSCIFUEBTF) □ Group of Self-Insured Employers□ Self-Insurer Security Fund □ Joint Powers Authority □ State □ Insurer□ Entity that provides physician network services 5.
Change of MPN name or MPN Applicant name: Provide new name and plan sections affected by the change within fifteen (15) business days of the change.
Change in Economic Profiling policy used by MPN Applicant or any entity contracted with MPN: Provide a copy of the revised policy or procedure.
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 belief, the information included in this modification is true and correct.” Name of Authorized Individual TitleOrganizationPhone Email Signature of Authorized Individual 6.
If the terminated medical provider does not agree to comply or upon agreement does not comply with these contractual terms and conditions, then MPN Applicant is not required to continue the provider’s services beyond the contract termination date.
Change in Service Area: Provide documentation in compliance with section 9767.5. Change of MPN name or MPN Applicant name: Provide new name and plan sections affected by the change within fifteen (15) business days of the change.
This policy will not require Applicant to provide for completion of treatment by a provider whose contract with MPN Applicant has been terminated or not renewed for reasons relating to a medical disciplinary cause or reason, as defined in paragraph (6) of subdivision (a) of Section 805 of the Business and Profession Code, or fraud or other criminal activity.
Provide a description of the entity’s qualifications to be an eligible MPN Applicant.