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Complaint / Independent Medical Review (IMR) Application Form


To complete and submit a Complaint / Independent Medical Review (IMR) Application form online:

  1. Select either link below:

    To complete and submit a Complaint / Independent Medical Review (IMR) Application 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:

    1. Select the language you want.
    2. Complete and sign the form.
    3. 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)

  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:

  1. Select the language you want.
  2. Complete and sign the form.
  3. 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)