DWCFORM9767.17.5PARTB.STRIKEOUTFillable

MPN response to petition for suspension or revocation of a medical provider network - Part B

CA Division of Workers Compensation · Workers Compensation

Verified current as of August 1, 2026

Medical provider network response to a petition seeking suspension or revocation of the network's certification under California workers' compensation law.

This form has fillable fields — you can complete it directly in the viewer on the right.
Loading…