Physician Contract Application (Independent Medical Reviewer) {DWC 9768.5}

DWC Form 9768.5 - PHYSICIAN CONTRACT APPLICATION (INDEPENDENT MEDICAL REVIEWER). This form is used by physicians who wish to serve as Independent Medical Reviewers for the California Division of Workers’ Compensation. The application gathers essential professional details, including licensure information, education, board certifications, hospital privileges, and any affiliations that could create conflicts of interest. Physicians must also disclose disciplinary history and confirm active, unrestricted license status. The form requires original signatures and supporting documents such as a California professional license and board certification. Applicants must agree to confidentiality requirements and compliance with Title 8 regulations governing Independent Medical Review. A privacy notice explains how submitted information may be used, and final acceptance occurs only when the Administrative Director signs the contract. www.FormsWorkflow.com