California Code of Regulations › Title 8 - Industrial Relations › Division 1 - Department of Industrial Relations › Chapter 4.5 - Division of Workers' Compensation › Subchapter 1 - Administrative Director-Administrative Rules › Article 3.6 - Independent Medical Review › Section 9768.10 - Independent Medical Review Application (Form)

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
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Instructions for MPN Contact:
At the time of
						the selection of the physician for a third opinion, you are required to notify
						the covered employee about the Independent Medical Review process and provide
						the covered employee with this "Independent Medical Review Application" form.
						You are required to fill out the "MPN Contact section" of the form. You must
						then send the form to the employee, who will fill out the top section of the
						form and send it to the Division of Workers' Compensation. The DWC will send
						you written notification of the name and contact information of the Independent
						Medical Reviewer. You must then send the employee's relevant medical records as
						defined by section
						9768.1(a)(11) to
						the Independent Medical Reviewer. A copy of the medical reports must also be
						sent to the employee.
Instructions for Injured Employee:
This
						application is being sent to you because you have requested a third opinion to
						address your dispute with your treating doctor's diagnosis, suggested test, or
						suggested medical treatment.
Please wait until you read the report from
						the third opinion doctor before you fill out this form.
If the report
						resolves your dispute, then you do not need to fill out this form. If you still
						have a dispute with your treating doctor, then you may request an Independent
						Medical Review by completing this form and sending it to:
Dept. of Industrial Relations
Division of Workers' Compensation
P.O. Box 71010
Oakland, CA 94612.
An Independent Medical Review is done by a physician who
						does not work directly with your doctor. You can visit that doctor and be
						examined or you can choose to have the doctor review your records. Indicate on
						the form whether you want to be examined (in-person examination) or if you only
						want to have your records reviewed.
The specialty of the doctor will be the same as the
						specialty of your treating physician, if possible. Not all types of doctors can
						be an Independent Medical Reviewer. You may select another type of doctor in
						case your doctor's specialty is not available. To do this, look at the list of
						specialists below and chose one type. Indicate this choice on the application.
						You will receive the name and contact information of the Independent Medical
						Reviewer from the Division of Workers' Compensation. When you receive the name
						of the Independent Medical Reviewer, you must make an appointment within 60
						days. The Independent Medical Reviewer is required to schedule an appointment
						with you within 30 days. If you fail to make the appointment with the
						Independent Medical Reviewer within 60 days, you will not be allowed to have an
						Independent Medical Review on this dispute.
Written notice must be made to the Administrative
						Director and MPN Contact if you wish to withdraw the request for an Independent
						Medical Review after this form has been submitted.
SPECIALTY CODES
MAI
Allergy and Immunology
MAA
Anesthesiology
MRS
Colon & Rectal Surgery
MDE
Dermatology
MEM
Emergency Medicine
MFP
Family Practice
MPM
General Preventive Medicine
MHD
Hand -- Orthopaedic Surgery, Plastic
								Surgery, General Surgery
MMM
Internal Medicine
MMV
Internal Medicine -- Cardiovascular
								Disease
MME
Internal Medicine -- Endocrinology
								Diabetes and Metabolism
MMG
Internal Medicine --
								Gastroenterology
MMH
Internal Medicine -- Hematology
MMI
Internal Medicine -- Infectious
								Disease
MMO
Internal Medicine -- Medical
								Oncology
MMN
Internal Medicine -- Nephrology
MMP
Internal Medicine -- Pulmonary
								Disease
MMR
Internal Medicine -- Rheumatology
MPN
Neurology
MNS
Neurological Surgery
MNM
Nuclear Medicine
MOG
Obstetrics and Gynecology
MPO
Occupational Medicine
MOP
Opthalmology
MOS
Orthopaedic Surgery
MTO
Otolaryngology
MAP
Pain Management -- Psychiatry and
								Neurology, Physical Medicine and Rehabilitation, Anesthesiology
MHA
Pathology
MEP
Pediatrics
MPR
Physical Medicine &
								Rehabilitation
MPS
Plastic Surgery
MPD
Psychiatry
MRD
Radiology
MSY
Surgery
MSG
Surgery -- General Vascular
MTS
Thoracic Surgery
MTX
Toxicology - Preventive Medicine,
								Pediatrics, Emergency
MUU
Urology
POD
Podiatry
DWC Form 9768.10
May 2007
1. New
						section filed 12-31-2004 as an emergency; operative 1-1-2005 (Register 2004,
						No. 53). A Certificate of Compliance must be transmitted to OAL by 5-2-2005 or
						emergency language will be repealed by operation of law on the following
						day.
2. Certificate of Compliance as to 12-31-2004 order, including
						amendment of section heading and section, transmitted to OAL 4-29-2005 and
						filed 6-10-2005 (Register 2005, No. 23).
3. Change without
						regulatory effect amending form filed 10-18-2006 pursuant to section
						100, title 1, California Code of
						Regulations (Register 2006, No. 42).
4. Change without regulatory
						effect amending section filed 5-23-2007 pursuant to section
						100, title 1, California Code of
						Regulations (Register 2007, No. 21).
Note: Authority cited: Sections
						  133 and
						  4616, Labor
						  Code. Reference: Sections
						  4616.3 and
						  4616.4, Labor
						  Code.