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To complete and submit an Online Independent Medical Review/Complaint Form:

To complete and submit an Independent Medical Review/Complaint Form online:

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:

Help Center
Department of Managed Health Care
980 9th Street, Suite 500
Sacramento, CA 95814-2725
FAX: 916-255-5241

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.

Complaint Form Independent Medical Review (IMR) Application form

English

English

Spanish (Español)

Spanish (Español)

Arabic (العربية)

Arabic (العربية)

Armenian (հայերեն լեզու)

Armenian (հայերեն լեզու)

Chinese (中文)

Chinese (中文)

Farsi (فارسی‎)

Farsi (فارسی‎)

Hmong (Hmoob)

Hmong (Hmoob)

Khmer/Cambodian

Khmer/Cambodian

Korean

Korean

Lao

Lao

Russian (Русский)

Russian (Русский)

Tagalog

Tagalog

Vietnamese (tiếng Việt)

Vietnamese (tiếng Việt)

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