If you want to give another person the authority to assist you with your IMR, you must also complete the Authorized Assistant Form.

First Name   Middle Initial   Last Name

Name of Parent or Guardian if Filing for Minor Child

Street Address

City   State   Zip

Day Phone #   Evening Phone #

Health Plan Name

Patient's Membership Number   Patient's Date of Birth (mm/dd/yy)

Do you have Medi-Cal?

Yes   No

Do you have Medicare or Medicare Advantage?

Yes   No

Have you filed a complaint or grievance with your health plan?

Yes   No

Are you seeking payment for a service that you have already received?

Yes   No
  (Use a separate sheet and attach other documents if needed.)

What is your health condition or doctor's diagnosis?


 
What medical treatment or service are you requesting?


 
How would you like this case to be decided?


 
Do you have a condition that is a serious threat to your health?       Yes   No
If "yes," please explain.


 
Did your health plan say that the treatment you want is (check one):
Not medically necessary   Experimental or investigational   Other


 
List the name and phone number of your primary care doctor and other doctors who have seen, treated or advised you for your condition. Are they in your health plan's network? (Use a separate sheet if needed.)


 
I am asking for an Independent Medical Review (IMR) to make a decision about my problem with my health plan. I allow my providers, past and present, and my health plan to release my medical records and information for this IMR. These records may include medical, mental health, substance abuse, HIV, diagnostic imaging reports, and other records related to my case. These records may also include non-medical records and any other information related to my case. I allow the Department of Managed Health Care (DMHC) and IMR staff to review these records and information. My permission will end one year from the date below, except as allowed by law. For example, the law allows the DMHC to continue to use my information internally. I can end my permission sooner if I wish. All the information that I have provided on this sheet is true.

Patient or Parent Signature   Date

Mail or fax this form and any attachments to: HMO Help Center, Department of Managed Health Care, IMR Unit, 980 Ninth St., Suite 500, Sacramento, CA 95814; FAX: (916) 255-5241



IMR Applications Instructions

If your health plan denies your request for medical services or treatment, you can file a complaint (grievance) with your plan. If you disagree with your plan's decision, you can ask the HMO Help Center at the Department of Managed Health Care for an Independent Medical Review (IMR). An IMR is a review of your case by doctors who are not part of your health plan. If the IMR is decided in your favor, your plan must give you the service or treatment you requested. You pay no costs for an IMR.

You Can Apply for an IMR if Your Health Plan:

Before You Apply

In most cases, you must complete your health plan's complaint process before you apply for an IMR. Your plan must give you a decision within 30 days or within 3 days if your problem is an immediate and serious threat to your health.

If your plan denied your treatment because it was experimental/ investigational, you do not have to take part in your plan's complaint process before you apply for an IMR.

You must apply for an IMR within six months after your health plan sends you a written response to your grievance. We may accept your application after six months, if we determine that circumstances prevented timely submission.

Please be aware that if you decide not to participate in the IMR process, you may be giving up your statutory rights to pursue legal action against your plan regarding the service or treatment you are requesting.

How to Apply

Fill out the IMR Application Form. Fill out the Authorized Assistant form if someone is helping you with your IMR. If you have medical records from non-contracting providers regarding your health care issue, please include them with your application. Your health plan will be required to obtain medical records from contracting providers.

Attach copies of letters or other documents about the treatment or service that your health plan denied. This can speed up the IMR process. Send copies of documents, not originals. The HMO Help Center cannot return documents.

If you have questions about filling out your application form, call the HMO Help Center at 1-888-HMO-2219 or TDD 1-877-688-9891. There is no charge for this call.

Mail or fax your form and any attachments to:

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

What Happens if You Qualify for an IMR?

The HMO Help Center will review your application and send you a letter within 7 days telling you that you qualify for an IMR. When all your information is received, including relevant medical records, the IMR decision will be made within 30 days, or within 3 to 7 days if your case is urgent. You will be notified of the decision made by the doctors who have reviewed your case. If the IMR is decided in your favor, your plan must give you the service or treatment you requested.

What Happens if You Do Not Qualify for an IMR?

Your issue will be reviewed through the Department's standard complaint process. You will receive a written notice of our decision within 30 days.

This Notice is Required by Law.

  • California's Knox-Keene Act gives the Department of Managed Health Care (DMHC) the authority to regulate health plans and investigate the complaints of health plan members.
  • The DMHC's HMO Help Center uses your personal information to investigate your problem with your health plan and to provide an Independent Medical Review if you qualify for one.
  • You give us this information voluntarily. You do not have to give us this information.
  • However, if you do not give us the information, we may not be able to investigate your complaint or provide an Independent Medical Review.
  • We may share your personal information, as needed, with the health plan and the doctors who are doing the Independent Medical Review.
  • We may also share your information with other government agencies as required or allowed by law.
  • You have a right to see your personal information. To do this, contact the DMHC Records Request Coordinator, DMHC, Office of Legal Services, 980 9th Street, Suite 500, Sacramento, CA 95814-2725, (916) 322-6727.
  • The law that requires this notice is the Information Practices Act of 1977 (California Civil Code Section 1798.17)




If you want to give someone the authority to assist you in your Independent Medical Review (IMR) or complaint, fill in Parts A and B below.

If you are a parent or legal guardian filing this IMR or complaint for a child under the age of 18, you do not need to complete this form.

If you are filing this IMR or complaint for a patient who cannot complete this form and you have legal authority to act for this patient, please complete Part B only. Also send a copy of the power of attorney for health care decisions or other legal document that says you can make decisions for the patient.

I allow the person named below in Part B to assist me in my IMR or complaint filed with the Department of Managed Health Care (DMHC). I allow the DMHC and IMR staff to share information about my medical condition(s) and care with the person named below. This information may include mental health treatment, HIV treatment or testing, alcohol or drug treatment, or other health care information.

I understand that only information related to my IMR or complaint will be shared.

My approval of this assistance is voluntary and I have the right to end it. If I want to end it, I must do so in writing.

Patient Signature   Date

Name of Person Assisting (print)

Signature of Person Assisting

Address

Relationship to Patient

Daytime Phone #

Evening Phone #

My power of attorney for health care decisions or other legal document is attached.