Submit an Independent Medical Review/Complaint Form

If Your Health Plan Denies Treatment Submit an Independent Medical Review/Complaint Form

Are you an enrollee with a complaint about your health plan? Has a service/treatment you or your doctor requested been denied, modified or delayed? The Help Center can help. Fill out and submit an Independent Medical Review/Complaint Form or call our Help Center at 1-888-466-2219 for assistance.

Once your Independent Medical Review/Complaint Form has been received, the Help Center will determine whether your complaint qualifies for an Independent Medical Review (IMR) or if it will be reviewed as a Consumer Complaint.

You must submit your Independent Medical Review/Complaint Form to the DMHC within six months after your health plan sends you a written decision about your issue.

Submit Online

To complete and submit an Independent Medical Review (IMR)/Complaint Form Online:

  1. Select either link below:
  2. Complete all required fields.
  3. Submit the form online.
  4. You will receive an e-mail notice that your form has been received.

Online submissions are through a secure web portal.

Submit by Mail or Fax

To complete and submit an Independent Medical Review (IMR)/Complaint Form by Mail or Fax:

  1. Select the language you want from the table below.
  2. Complete and sign the form.
  3. Fax or mail the form and copies of any supporting documents to:

Help Center
Department of Managed Health Care
980 9th Street, Suite 500
Sacramento, CA 95814-2725

FAX: 916-255-5241

You must have Adobe Reader to print the forms below. You can download Adobe Reader for free to your computer. Click for directions

Independent Medical Review (IMR)/Complaint Forms (various languages)
English

Independent Medical Review (IMR) Application / Complaint Form

Español

Formulario de queja/solicitud de revisión médica independiente (IMR)

Arabic

طلب مراجعة طبية مستقلة/ نموذج الشكوى

Armenian

ԱՆԿԱԽ ԲԺՇԿԱԿԱՆ ՎԵՐԱՔՆՆՈՒԹԵԱՆ ԴԻՄՈՒՄՆԱԳԻՐ (IMR)/ԳԱՆԳԱՏԻ ՁԵՒԱԹՈՒՂԹ

Chinese

獨立醫療審查申請(IMR)/投訴表格

Farsi

فرم درخواست برای بازنگری پزشکی مستقل (IMR)/شکایت

Hmong

DAIM NTAWV TSO NPE THOV KOM ROV XYUAS KEV KHO MOB UAS NCAJ Nrab (IMR)/Daim Foos Tsis Txaus Siab

Khmer/Cambodian

ពាក្យស្នើសុំការពិនិត្យវេជ្ជសាស្រ្តឯករាជ្យ (IMR)/សំណុំបែបបទបណ្តឹង

Korean

독립 의료 검토 신청서(IMR)/불만양식

Lao

ໃບສະໝັກ(IMR)/ແບບຟອມຄຳຮ້ອງຂໍທົບທວນການເບິ່ງແຍງສຸຂະພາບແບບອິດສະລະ 

Russian

Заявка на проведение независимой медицинской проверки (IMR)/Форма жалобы

Tagalog 

PORMA NG REKLAMO/APLIKASYON SA MALAYANG PAGSUSURING MEDIKAL

Vietnamese

MẪU ĐƠN YÊU CẦU XEM XÉT Y TẾ ĐỘC LẬP (IMR)/KHIẾU NẠI

If you want to give another person permission to help you with your Independent Medical Review (IMR) or Complaint, use the form below. We can not talk to another person about your case unless you sign this form:

What Happens Next?

The Help Center will review your application and send you an acknowledgement of receipt letter within 5 days. Urgent IMR decisions are typically determined within 10 days after the case has qualified for an IMR and the required documentation has been received by the DMHC’s Independent Medical Review organization. Non-urgent IMR’s and Consumer Complaint decisions are typically decided within 30 days.

Have questions? Take a look at our Frequently Asked Questions

If you would like to see past IMR decisions, follow this link to Search IMR Decisions