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's Attorney's Name, if applicable Employee Phone Number / Fax Attorney's Phone Number / Fax Employee's Address 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 behalf of the injured employee), authorize the release of relevant medical records to the Independent Medical Reviewer.
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 Em __________________________________________ Insurer __________________________________________ Medical Provider Network Dat
ployer __________________________________________________ Claim Number __________________________________________________ e of Injury
Treating Physician Sp
2nd Opinion Physician and specialty
3rd 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:
Phone number, fax, and email of MPN Contact
___________________________________ _ ______________________________________________________________________________ Name of MPN Contact Address
DWC Form 9768.10 May 2007 1
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 c overed e mployee abo ut t he Independent M edical R eview process a nd p rovide t he co vered employee wi th t his "I ndependent Medical Review Application" form. Yo u are req uired to fill out the "MPN Contact section" of th e 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 th e 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 c opy 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 t hird opinion to address your dispute with your treating doctor's diagnosis, suggested test, o r 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 phy sician who does not work directly with your doctor. Yo u can v isit that doctor and be examined or you can choose to have the doctor review your records. I ndicate 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 o f specialists below and chose one type. Ind icate this choice on the application. You will receiv e 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 y ou 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 MRS Colon & Rectal Surgery MEM Em ergency Medicine MPM General Preventive Medicine MMM Internal Medicine MME Internal Medicine Endocrinology Diabetes and Metabolism MMH Internal Medicine Hematology MMO Internal Medicine Medical Oncology MMP Internal Medicine Pulmonary Disease MPN N eurology MNM Nuclea r Medicine MPO Occu pational Medicine MOS Ort hopaedic Surgery MAP Pain Management Psychiatry and Neurology, Physical Medicine and Rehabilitation, Anesthesiology MEP Pediatrics MPS Plastic Surgery MRD R adiology MSG Surgery General Vascular MTX Toxicology Preventive Medicine, Pediatrics, Emergency POD Podiatry MAA Anest hesiology MDE Derm atology MFP Family Practice MHD Hand Orthopaedic Surgery, Plastic Surgery, General Surgery MMV Internal Medicine Cardiovascular Disease MMG Internal Medicine - Gastroenterology MMI Internal Medicine Infectious Disease MMN Internal Medicine - Nephrology MMR Internal Medicine Rheumatology MNS N eurological Surgery MOG Obstetrics and Gynecology MOP Op hthalmology MTO O tolaryngology MHA Pathology MPR Physical Medicine & Rehabilitation MPD Psychiatry MSY Surge ry MTS Thoracic Surgery MUU U rology
DWC Form 9768.10 May 2007