CA Medical Provider Network (MPN) Forms and Affidavits

Resources

DWC-7 Workers Comp Posting Notice (English and Spanish) - REVISED
  • This notice is required. Also called Notice to Employees – Injuries Caused by Work. Post both English and Spanish version where there are Spanish-speaking employees. 

Complete MPN Employee Notification
  • No longer required to be posted. BHHC will send at the time the claim is reported. Employers may post both English and Spanish version where there are Spanish-speaking employees.

DWC Time of Hire Pamphlet (English) - REVISED (formerly Facts about Workers Comp)
DWC Time of Hire Pamphlet (Spanish)REVISED (formerly Facts about Workers Comp)
  • Required to be provided to all new employees at time of hire. Distribute both English and Spanish version when new hire is Spanish-speaking employee. Can now be distributed electronically. New version is in 8-1/2 x 11 format.

MPN Implementation Notice (English) - NEW
MPN Implementation Notice (Spanish) - NEW
  • No longer required to be provided to all new employees at time of hire. 

DWC-1 Employees Claim Form - REVISED
  • Required to be provided to injured employees for injuries (as of October 8, 2010). Provide at time of injury. Please also note that the State has implemented the following changes relating to the distribution of the blue ‘MPN Pamphlets’ and the red 'Facts for Injured Worker' Pamphlets:

MPN Pamphlets (English and Spanish) - NO LONGER REQUIRED
  • No longer required to be distributed at time of hire or at time of new policy bind. BHHC will send to injured employee at the time claim is reported.

DWC Factsheets for Injured Workers (English) - REVISED (formerly Facts for Injured Workers)
DWC Factsheets for Injured Workers (Spanish) - REVISED (formerly Facts for Injured Workers)
  • Only required to be distributed to employees that are injured due to a violent crime.

MPN Implementation Affidavit 
  • No longer required. This form signifies that the MPN Implementation notice has been distributed. Should be completed when you have a new hire. Fax completed form to BHHC at (866) 348-3588.

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