Independent Medical Review Application (Division of Workers' Compensation ­ 8 CCR §9768.10 Mandatory Form) __________________________________________________________________________________________________________________________ ________ _________ Employee Section: The Employee shall complete this section and send the completed form to the Administrative Director. Mailing address: Dept. of Industrial Relations, Division of Workers' Compensation, P.O. Box 71010, Oakland, CA 94612. _____________________________________ Employee Name _________________________________________________________________________ _______________________ ______________________________ Employee Phone Number / Fax ______________________________________________ Employee's Address ____________________________________________________________ Employee's Attorney's Name, if applicable Attorney's Phone Number / Fax Attorney's Address Pursuant to Labor Code section 4616.4, I request that the Administrative Director set an Independent Medical Review within 30 days from receipt of this Application. Check one: Request for In-Person Examination Request for Record Review (no In-Person Examination) Is interpreter needed for exam? ______ If yes, language:__________________________________________________________ Describe diagnosis and part of body affected:___________________________________________________________________________ Reason for request for Independent Medical Review. Please explain if the dispute involves the diagnosis, treatment or a test (attach additional page or additional materials, such as medical records, if necessary): ________________________________________________________________________________________________________ Select an alternative specialty, other than specialty of treating physician, if any, from the list on the instructions for this form: ________________________________________________________________________________________________________ Release: I, ___________________ (injured employee or person authorized pursuant to law to act on behalf of the injured employee), authorize the release of relevant medical records to the Independent Medical Reviewer. _____________________________________________ ___________________________ Signature of injured employee or authorized person Date ___________________________________________________________________________________________________________________ Medical Provider Network Contact Section: The MPN Contact shall complete this section and send the form to the employee. _________________________________________ Employee __________________________________________ Insurer __________________________________________ Medical Provider Network __________________________________________ Employer __________________________________________________ Claim Number __________________________________________________ Date of Injury _______________________________________ Treating Physician _______________________________________ 2nd Opinion Physician and specialty _________________ Specialty ______________________________________ Address __________________________________________________________ 3rd Opinion Physician and specialty Select an alternative specialty other than specialty of treating physician, if any, from the list on the back of this form: ________________________________________________________________________________________________________ I declare under penalty of perjury that I mailed a copy of the Application for IMR to the above named Employee on _____________________________ _____________________________ ____________________________________ Date Signature Phone number, fax, and email of MPN Contact ___________________________________ _______________________________________________________________________________ Name of MPN Contact Address DWC Form 9768.10 May 2007 1 American LegalNet, Inc. www.FormsWorkflow.com Instructions for Independent Medical Review Application Form Instructions for MPN Contact: At the time of the selection of the physician for a third opinion, you are required to notify the covered employee about the Independent Medical Review process and provide the covered employee with this "Independent Medical Review Application" form. You are required to fill out the "MPN Contact section" of the form. You must then send the form to the employee, who will fill out the top section of the form and send it to the Division of Workers' Compensation. The DWC will send you written notification of the name and contact information of the Independent Medical Reviewer. You must then send the employee's relevant medical records as defined by section 9768.1(a)(11) to the Independent Medical Reviewer. A copy of the medical reports must also be sent to the employee. Instructions for Injured Employee: This application is being sent to you because you have requested a third opinion to address your dispute with your treating doctor's diagnosis, suggested test, or suggested medical treatment. Please wait until you read the report from the third opinion doctor before you fill out this form. If the report resolves your dispute, then you do not need to fill out this form. If you still have a dispute with your treating doctor, then you may request an Independent Medical Review by completing this form and sending it to: Dept. of Industrial Relations Division of Workers' Compensation P.O. Box 71010 Oakland, CA 94612. An Independent Medical Review is done by a physician who does not work directly with your doctor. You can visit that doctor and be examined or you can choose to have the doctor review your records. Indicate on the form whether you want to be examined (in-person examination) or if you only want to have your records reviewed. The specialty of the doctor will be the same as the specialty of your treating physician, if possible. Not all types of doctors can be an Independent Medical Reviewer. You may select another type of doctor in case your doctor's specialty is not available. To do this, look at the list of specialists below and chose one type. Indicate this choice on the application. You will receive the name and contact information of the Independent Medical Reviewer from the Division of Workers' Compensation. When you receive the name of the Independent Medical Reviewer, you must make an appointment within 60 days. The Independent Medical Reviewer is required to schedule an appointment with you within 30 days. If you fail to make th