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If your health plan denies treatment apply for an Independent Medical Review (IMR), 60% of enrollees receive requested treatment through IMR

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

To complete and submit an Independent Medical Review (IMR) Application / Complaint Form online:

Online submissions are through a secure web portal.

To print a blank Independent Medical Review (IMR) Application / Complaint 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.

Independent Medical Review (IMR) Application / Complaint Forms (various languages)

Independent Medical Review (IMR) Application / Complaint Form - English

Formulario de queja/solicitud de revisión médica independiente (IMR) - Español

طلب مراجعة طبية مستقلة/ نموذج الشكوى – Arabic

ԱՆԿԱԽ ԲԺՇԿԱԿԱՆ ՎԵՐԱՔՆՆՈՒԹԵԱՆ ԴԻՄՈՒՄՆԱԳԻՐ (IMR)/ԳԱՆԳԱՏԻ ՁԵՒԱԹՈՒՂԹ – Armenian

獨立醫療審查申請(IMR)/投訴表格 – Chinese

فرم درخواست برای بازنگری پزشکی مستقل (IMR)/شکایت – Farsi

DAIM NTAWV TSO NPE THOV KOM ROV XYUAS KEV KHO MOB UAS NCAJ Nrab (IMR)/Daim Foos Tsis Txaus Siab – Hmong

ពាក្យស្នើសុំការពិនិត្យវេជ្ជសាស្រ្តឯករាជ្យ (IMR)/សំណុំបែបបទបណ្តឹង - Khmer/Cambodian

독립 의료 검토 신청서(IMR)/불만양식 – Korean

ໃບສະໝັກ(IMR)/ແບບຟອມຄຳຮ້ອງຂໍທົບທວນການເບິ່ງແຍງສຸຂະພາບແບບອິດສະລະ - Lao

Заявка на проведение независимой медицинской проверки (IMR)/Форма жалобы – Russian

PORMA NG REKLAMO/APLIKASYON SA MALAYANG PAGSUSURING MEDIKAL – Tagalog

MẪU ĐƠN YÊU CẦU XEM XÉT Y TẾ ĐỘC LẬP (IMR)/KHIẾU NẠI - Vietnamese

 

Authorized Assistant Form (English)

Formulario de Asistente Autorizado (Español)