Petition Appealing Administrative Directors Independent Medical Review Determination

PETITION APPEALING ADMINISTRATIVE DIRECTOR’S INDEPENDENT MEDICAL REVIEW DETERMINATION. This is a California Workers’ Compensation Appeals Board form used when an applicant seeks judicial review of an IMR decision regarding medical treatment disputes. The petition allows the applicant to identify the IMR determination date and assert one or more statutory grounds for appeal, such as acting in excess of authority, fraud, material conflict of interest, bias, or plainly erroneous factual findings. The form requires a detailed statement explaining each objection and the relevant supporting facts. Petitioners must file the document at the district office with venue and attach the IMR determination, verification, and proof of service. www.FormsWorkflow.com