IMR Application Form
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- Fill out the IMR Application form by hand or on the computer.
- Print and sign the form.
- Fax or mail the IMR Application Form and copies of any other needed records to:
HMO Help Center
Department of Managed Health Care
980 Ninth Street, Suite 500
Sacramento, CA 95814-2725
FAX: 1-916-255-5241
PDF
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If you have Adobe Reader, your computer will open the form. The form needs your signature. Fill in the blanks online, print the form, sign it and mail it to us.