Independent Medical Review Application (8 CCR 9768.10 Mandatory Form) {9768.10}

DWC Form 9768.10 - INDEPENDENT MEDICAL REVIEW APPLICATION. This is a mandatory California form used by injured employees in a Medical Provider Network (MPN) to request an independent review when disputes remain after the third-opinion evaluation. The employee completes the top section to identify the diagnosis, affected body parts, reason for the IMR request, preferred examination method, and any alternative medical specialty. The form also includes a release authorizing medical records to be sent to the Independent Medical Reviewer. The MPN contact must complete their section, provide required physician information, and mail the form to the employee. Instructions clarify when IMR is appropriate, specialty selection, and deadlines for scheduling the appointment with the reviewer. www.FormsWorkflow.com