Examples of MPN Applicant in a sentence
Change in Economic Profiling policy used by MPN Applicant or any entity contracted with MPN: Provide a copy of the revised policy or procedure.
Provide a description of the entity’s qualifications to be an eligible MPN Applicant.
The MPN Applicant shall ensure each injured covered employee is given written notice of the date of termination or cessation of use of its MPN.
An implementation notice is not required if the MPN Applicant or insured employer is changing from one MPN to another MPN within 60 days.
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.
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.
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 ability, the information included in this application is true and correct.” Name of Authorized IndividualTitleOrganizationPhone/EmailSignature of Authorized Individual 11.
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 IndividualTitle Organization Phone Email Signature of Authorized Individual 6.
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.Eligibility Status of MPN Applicant □ Self-Insured Employer (including SISF) □ Insurer (including CIGA, UEBTF) □ Group of Self-Insured Employers □ Joint Powers Authority □ State □ Entity that provides physician network services 5.