Get Final Dwc Form Imr.docx - Dir Ca

This guide provides clear and detailed instructions for completing the FINAL DWC Form IMR online. Following these steps will ensure that you properly submit your request for an independent medical review, in accordance with California workers’ compensation protocols.

Follow the steps to fill out the FINAL DWC Form IMR effectively.

1. Click the ‘Get Form’ button to obtain the form and open it in the document editor.
2. Begin filling out the application by providing your full name, including first name, middle initial, and last name in the designated fields.
3. Complete the address section with your current residential address, ensuring accuracy to facilitate communication.
4. Enter your phone number in the corresponding field to ensure they can contact you if needed.
5. Fill in the employer's name and claim number as indicated on your insurance documents.
6. Record the date of your injury in the specified format (MM/DD/YYYY) for clarity.
7. If applicable, include the WCIS jurisdictional claim number and EAMS case number if you have them available.
8. Provide information about your requesting physician, including their name, practice name, specialty, contact number, and address.
9. Complete the claims administrator’s details, including their name and contact information.
10. In the disputed medical treatment section, outline the primary diagnosis and include the corresponding ICD code where appropriate.
11. Indicate whether the claims administrator is disputing liability for the requested medical treatment by selecting 'Yes' or 'No' and providing a reason if necessary.
12. List all specific medical services, goods, or items that were denied or modified, using additional pages if necessary.
13. In the consent section, review and verify your agreement to allow the release of your medical records and information for your independent medical review.
14. Sign and date the application before proceeding to submission.
15. Submit your application along with a copy of the written determination letter via mail or fax to the specified address for DWC-IMR.
16. Lastly, send a copy of the signed application to your claims administrator, excluding the written determination letter.

Begin filling out your documents online today to ensure a smooth independent medical review process.