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MAXIMUS FEDERAL SERVICES, INC.
Independent Medical Review
P.O. Box 138009
Sacramento, CA 958138009
(855) 8658873 Fax: (916) 6054270Independent Medical Review Final Determination Lettered: Select Date
Employee:
Claim
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How to fill out dwc independent medical review
How to fill out dwc independent medical review
01
To fill out DWC Independent Medical Review form, follow these steps:
02
Fill out your personal information: Provide your full name, address, phone number, and email address.
03
Provide case details: Indicate the case number and the name of the injured worker.
04
Identify the medical provider: Fill in the name and address of the physician or medical provider.
05
Describe the medical treatment: Provide a detailed description of the medical treatment in question. Include dates, types of treatment, and any supporting documentation.
06
State the reason for the review: Clearly explain why you believe an independent medical review is necessary, highlighting any discrepancies or concerns.
07
Attach supporting documents: Include any relevant medical records, test results, or documentation that supports your request for an independent medical review.
08
Sign and date the form: Once you have completed all the necessary sections, sign and date the DWC Independent Medical Review form.
09
Submit the form: Send the completed form, along with any supporting documents, to the designated address as specified on the form or by the Workers' Compensation Appeals Board.
Who needs dwc independent medical review?
01
DWC Independent Medical Review is needed by individuals involved in a workers' compensation case.
02
This includes injured workers, employers, insurance carriers, and other parties seeking an independent evaluation of a medical treatment dispute.
03
The independent medical review helps to ensure fair and unbiased assessments of medical treatment decisions, addressing any disagreements or concerns that may arise during the workers' compensation process.
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What is dwc independent medical review?
DWC independent medical review is a process used to resolve disputes regarding the medical treatment and care of injured workers.
Who is required to file dwc independent medical review?
Any party involved in a workers' compensation claim may request a DWC independent medical review.
How to fill out dwc independent medical review?
To fill out a DWC independent medical review, you must provide complete and accurate information about the medical treatment dispute.
What is the purpose of dwc independent medical review?
The purpose of DWC independent medical review is to ensure injured workers receive appropriate medical treatment and to resolve disputes regarding medical care.
What information must be reported on dwc independent medical review?
On a DWC independent medical review, you must report details of the medical treatment in dispute, as well as relevant medical records and opinions.
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