To complete and submit an Independent Medical Review/Complaint Form online:
- 1. Select either link below:
- 2. Complete all required fields.
- 3. Submit the form online.
- 4. You will receive an e-mail notice that your form has been received.
Online submissions are through a secure web portal.
To print a blank PDF Complaint or Independent Medical Review (IMR) Application form to mail or fax:
- Select the language you want.
- Complete and sign the form.
- Fax or mail the form and copies of any supporting documents to:
Department of Managed Health Care
980 9th Street, Suite 500
Sacramento, CA 95814-2725
You must have a computer program called Adobe Reader to print the forms below. You can download Adobe Reader for free to your computer. Click on Adobe for directions.
Authorized Assistant Form