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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

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What is independent medical review application?

Independent medical review application is a formal request made by an individual to have their medical case reviewed by an independent panel of medical experts.

Who is required to file independent medical review application?

Individuals who have been denied medical treatment or services by their insurance company and wish to appeal the decision can file an independent medical review application.

How to fill out independent medical review application?

To fill out an independent medical review application, one must provide their personal information, details of the denied treatment or services, any supporting documentation, and explanation of why the denial should be overturned.

What is the purpose of independent medical review application?

The purpose of independent medical review application is to seek an impartial review of denied medical treatment or services, ensuring that the decision made by the insurance company is fair and appropriate.

What information must be reported on independent medical review application?

On an independent medical review application, one must report their personal information, insurance details, description of the denied treatment or services, supporting documents, and reasons why the denial should be overturned.

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