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State of California Health and Human Services Agency Department of Managed Health Care INDEPENDENT MEDICAL REVIEW APPLICATION Laotian DMC 20086 New: 01/02 Rev: 09/12 MR,

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What is independent medical review applicationlaotian?

The independent medical review applicationlaotian is a formal request for an impartial review of medical decision by a third-party organization.

Who is required to file independent medical review applicationlaotian?

Any individual who disagrees with a medical decision made by their insurance company.

How to fill out independent medical review applicationlaotian?

The application can be filled out online or by requesting a paper form from the insurance company.

What is the purpose of independent medical review applicationlaotian?

The purpose is to ensure fair and unbiased review of medical decisions made by insurance companies.

What information must be reported on independent medical review applicationlaotian?

The application must include the individual's personal information, details of the medical decision being disputed, and any supporting documentation.

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