Get Independent Medical Review Application - California Department Of ... - Dmhc Ca

Filling out the Independent Medical Review Application is an essential step for individuals seeking an impartial evaluation of their health plan's decisions. This guide provides clear, step-by-step instructions on how to complete the application online, ensuring you proceed with confidence and clarity.

Follow the steps to effectively complete your application.

1. Press the ‘Get Form’ button to access the Independent Medical Review Application form and open it in the editing interface.
2. Begin by filling in your personal information, including your first name, middle initial, last name, and the name of a parent or guardian if applicable. Ensure your contact details, such as street address, city, state, and phone numbers, are accurate.
3. Indicate your health plan name and membership number. You will also need to provide your date of birth and gender. Confirm if you have Medi-Cal or Medicare by selecting 'Yes' or 'No'.
4. Respond to questions about previous complaints filed with your health plan and if you are seeking payment for services already received.
5. Detail your health condition or doctor's diagnosis in the relevant section, followed by the specific medical treatment or service you are requesting.
6. State how you would like your case to be decided and whether your condition poses a serious threat to your health, providing explanations if necessary.
7. List the names and contact information of your primary care doctor and other healthcare providers who have treated or advised you regarding your condition, specifying if they are within your health plan’s network.
8. Complete the authorization allowing medical records and information to be shared with the review body, followed by signing and dating the application.
9. After thoroughly reviewing your completed application and ensuring all necessary documents are attached, you can save changes, download, print, or share the form as required. Then, mail or fax your submission to the designated Help Center.

Take action today and complete your Independent Medical Review Application online.