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IMR Application Form


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  1. Select then print an IMR Application Form.
  2. Fill out the IMR Application Form.
  3. Sign the IMR Application Form.
  4. Fax or mail the IMR Application Form and copies of any other needed records to:

Help Center
Department of Managed Health Care
980 9th Street, Suite 500
Sacramento, CA 95814-2725

FAX: 916-255-5241

What is a PDF form
PDF stands for Portable Document Format. In order to use a form marked PDF, you must have Adobe Reader. This is a free software program. If you have Adobe Acrobat or Adobe Professional, you will also be able to use these forms.

If you click on the PDF link and you see a message that says error, you may not have the Adobe Reader on your computer. You can download Adobe Reader for free to your computer. Click on Adobe. You will be given directions on how to download the program.

For “Fill out then print” forms (English or Spanish): If you have Adobe Reader, your computer will open the form. Fill in the blanks online then print the form. You need to sign the form before you send it to us.