Independent Medical Review/Complaint Forms

Independent Medical Review/Complaint Forms

Submit an IMR / Complaint Form by Mail or Fax

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:

Help Center

Department of Managed Health Care 980 9th Street, Suite 500 Sacramento, CA 95814




Authorized Assistant Form

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)

Independent Medical Review / Complaint Forms

You must have Adobe Reader to print the forms below. You can download Adobe Reader for free to your computer.