CA Medical Provider Network (MPN) Forms and Resources

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. 

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.

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:

Complete MPN Employee Notification

• 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 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.

California Utilization Review Plan

• BHHC’s utilization review policies & procedures for the state of California, in compliance with California Labor Code Section 4610.(g)(5).

  Section 4610.(g)(5)

  (5) On or before July 1, 2018, each employer, either directly or through its insurer or an entity with which an employer or insurer contracts for utilization review services, shall submit a description of the utilization review process that modifies or denies requests for authorization of medical treatment and the written policies and procedures to the administrative director for approval. Approved utilization review process descriptions and the accompanying written policies and procedures shall be disclosed by the employer to employees and physicians and made available to the public by posting on the employer’s, claims administrator’s, or utilization review organization’s Internet Web site.

California Utilization Review Plan