Declaration - SDRMA - 2011-05-31 DECLARAII:ONT
DECLARATION OF CQ51 rrleset ti- (EMPLOYER NAME)
IN SUPPORT OF MEDICAL PROVIDER NETWORK
NOTICE AND APPLICATION
I,the undersigned Officer or Employee of Cos+w M�s� Sw,:+c .� 17 5�' �� (EMPLOYER NAME), have
been designated by She rrj h<< 1 c b (EMPLOYER NAME)to affirm the process by
which Cas-I-14 Mes•t- Sc,n c;. ,tA✓,rEMPLOYER NAME)notified all covered employees regarding
the implementation of a Medical Provider Network(MPN)for workers'compensation medical treatment and in
accordance with Labor Code§4616 et seq. I hereby declare as follows:
1.That the Notification of MPN Implementation,attached hereto as Exhibit A("Employee Notification"),along
with the pamphlet entitled "WellComp Medical Provider Network"attached hereto as Exhibit B ("Employee
Notice"),concerning the use of the Medical Provider Network has been provided to each and every covered
employee in accordance with Labor Code§4616.3 and California Code of Regulations,Ttle 8§9767.12,30
days prior to the implementation of such Medical Provider Network on September 1, 2010.
2.That the method of provision of the Employee Notification and Employee Notice prior to implementing the
MPN was pr"J- ro t l e cD.s (INSERT I.E.,PAYROLL ENCLOSURE,ETC.)
on 1 0) ( /10 (DATE).The Employee Notification was provided in English and Spanish and
the Employee Notice was provided in English and offered in Spanish,and meets the employee notification
requirements pursuant to California Code of Regulations,Title 8, §9767.12.
3.To ensure ongoing Notification of MPN Implementation and compliance with Labor Code§9767.6,
C_to i mss Srv.,�� D,Skr1{EMPLOYERNAME)has implemented a Notification Policy for all new
employees and those covered employees sustaining industrial injury post the MPN Implementation date.
I declare under penalty of perjury the foregoing is true and correct to the best of my knowledge, understanding
and ability.
Dated this 315'1/2—day of (Yl q j ,201m in Co 544s- Y`n eS a C A ��2'1-,California.
• EMPLOYER NAME: J
Cosh A (-Y-1 ._s sir
TITLE:
SIGNATURE`
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