NOTE: The DMHC strongly encourages you to file an IMR or Complaint form electronically through the online option (English / Español) to process your request as quickly as possible. Filing by mail may take longer to process.
Please select the desired form from the list below. Once completed, please sign and either mail or fax the form and copies of any supporting documents to:
Department of Managed Health Care 980 9th Street, Suite 500 Sacramento, CA 95814
916-255-5241
If you want to give another person permission to help you with your Independent Medical Review (IMR) or Complaint, use the form below. You have the option to send the form either as an attachment with your online IMR/Complaint Form, or with your supporting documents by mail or fax.
We cannot talk to another person about your case unless you sign these forms:
Authorized Assistant Form (English) / Formulario de Asistente Autorizado (Español)
DMHC Legal Representative for Deceased Patient Form (English)
You must have Adobe Reader to print the forms below. You can download Adobe Reader for free to your computer.
English
Español
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Armenian
Chinese
Farsi
Hindi
Hmong
Japanese
Khmer/ Cambodian
Korean
Lao
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Russian
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Thai
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Have additional questions? Take a look at our Frequently Asked Questions.