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Independent Medical Review Application

(Division of Workers’ Compensation – 8 CCR §9768.10 Mandatory Form)

Employee Section: The Employee shall complete this section and send the completed form to the Administrative Director.

Mailing address: Dept. of Industrial Relations, Division of Workers’ Compensation, P.O. Box 71010, Oakland, CA 94612.

Employee Name

Employee Phone Number / Fax

Employee’s Address

Employee’s Attorney’s Name, if applicable

Attorney’s Phone Number / Fax

Attorney’s Address

Pursuant to Labor Code section 4616.4, I request that the Administrative Director set an Independent Medical Review

within 30 days from receipt of this Application.

Check one:

Request for In-Person Examination

Request for Record Review (no In-Person Examination)

Is interpreter needed for exam? ______ If yes, language:__________________________________________________________

Describe diagnosis and part of body affected:

___________________________________________________________________________

Reason for request for Independent Medical Review. Please explain if the dispute involves the diagnosis, treatment or a test

(attach additional page or additional materials, such as medical records, if necessary):

________________________________________________________________________________________________________

Select an alternative specialty, other than specialty of treating physician, if any, from the list on the instructions for this form:

________________________________________________________________________________________________________

Release: I,

(injured employee or person authorized pursuant to law to act on

Independent Medical Reviewer

behalf of the injured employee), authorize the release of relevant medical records to the

Signature of injured employee or authorized person

Date

___________________________________________________________________________________________________________________

Medical Provider Network Contact Section: The MPN Contact shall complete this section and send the form to the employee.

__________________________________________

_________________________________________

Employee

Employer

__________________________________________

__________________________________________________

Insurer

Claim Number

__________________________________________

__________________________________________________

Medical Provider Network

Date of Injury

_______________________________________

______________

______________________________________

Treating Physician

Specialty

Address

_______________________________________

__________________________________________________________

2nd Opinion Physician and specialty

Opinion Physician and specialty

Select an alternative specialty other than specialty of treating physician, if any, from the list on the back of this form:

________________________________________________________________________________________________________

I declare under penalty of perjury that I mailed a copy of the Application for IMR to the above named Employee on

________________

Date

Signature

Phone number, fax, and email of MPN Contact

___________________________________ _ ______________________________________________________________________________

Name of MPN Contact

Address

DWC Form 9768.10

May 2007

Independent Medical Review Application

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