Fillable Independent Medical Review Application (Page 2 of 2) in pdf

Instructions for Independent Medical Review Application Form

Instructions for MPN Contact: At the time of the selection of the physician for a third opinion, you are required to notify

the covered employee about the Independent Medical Review process and provide the covered employee with this “Independent

Medical Review Application” form. You are required to fill out the “MPN Contact section” of the form. You must then send the

form to the employee, who will fill out the top section of the form and send it to the Division of Workers’ Compensation. The DWC

will send you written notification of the name and contact information of the Independent Medical Reviewer. You must then send

the employee’s relevant medical records as defined by section 9768.1(a)(11) to the Independent Medical Reviewer. A copy of the

medical reports must also be sent to the employee.

Instructions for Injured Employee: This application is being sent to you because you have requested a third opinion to

address your dispute with your treating doctor’s diagnosis, suggested test, or suggested medical treatment. Please wait until you

read the report from the third opinion doctor before you fill out this form. If the report resolves your dispute, then you do not

need to fill out this form. If you still have a dispute with your treating doctor, then you may request an Independent Medical Review

by completing this form and sending it to:

Dept. of Industrial Relations

Division of Workers’ Compensation

P.O. Box 71010

Oakland, CA 94612.

An Independent Medical Review is done by a physician who does not work directly with your doctor. You can visit that

doctor and be examined or you can choose to have the doctor review your records. Indicate on the form whether you want to be

examined (in-person examination) or if you only want to have your records reviewed.

The specialty of the doctor will be the same as the specialty of your treating physician, if possible. Not all types of doctors

can be an Independent Medical Reviewer. You may select another type of doctor in case your doctor’s specialty is not available. To

do this, look at the list of specialists below and chose one type. Indicate this choice on the application. You will receive the name

and contact information of the Independent Medical Reviewer from the Division of Workers’ Compensation. When you receive the

name of the Independent Medical Reviewer, you must make an appointment within 60 days. The Independent Medical Reviewer is

required to schedule an appointment with you within 30 days. If you fail to make the appointment with the Independent Medical

Reviewer within 60 days, you will not be allowed to have an Independent Medical Review on this dispute. Written notice must be

made to the Administrative Director and MPN Contact if you wish to withdraw the request for an Independent Medical

Review after this form has been submitted.

SPECIALTY CODES

MAI

Allergy and Immunology

MAA

Anesthesiology

MRS

Colon & Rectal Surgery

MDE

Dermatology

MEM

Emergency Medicine

MFP

Family Practice

MPM

General Preventive Medicine

MHD

Hand – Orthopaedic Surgery, Plastic Surgery, General

Surgery

MMM

Internal Medicine

MMV

Internal Medicine – Cardiovascular Disease

MME

Internal Medicine – Endocrinology Diabetes and

MMG

Internal Medicine - Gastroenterology

Metabolism

MMH

Internal Medicine – Hematology

MMI

Internal Medicine – Infectious Disease

MMO

Internal Medicine – Medical Oncology

MMN

Internal Medicine - Nephrology

MMP

Internal Medicine – Pulmonary Disease

MMR

Internal Medicine – Rheumatology

MPN

Neurology

MNS

Neurological Surgery

MNM

Nuclear Medicine

MOG

Obstetrics and Gynecology

MPO

Occupational Medicine

MOP

Ophthalmology

MOS

Orthopaedic Surgery

MTO

Otolaryngology

MAP

Pain Management –Psychiatry and Neurology,

MHA

Pathology

Physical Medicine and Rehabilitation, Anesthesiology

MEP

Pediatrics

MPR

Physical Medicine & Rehabilitation

MPS

Plastic Surgery

MPD

Psychiatry

MRD

Radiology

MSY

Surgery

MSG

Surgery – General Vascular

MTS

Thoracic Surgery

MTX

Toxicology – Preventive Medicine, Pediatrics,

MUU

Urology

Emergency

POD

Podiatry

DWC Form 9768.10

May 2007

Independent Medical Review Application Page 2

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