Find the Right California Workers' Comp Form

Throughout the course of any Workers’ Compensation case, an injured worker will receive a wide variety of forms, regarding everything from medical treatment to financial benefits. It is extremely important to read the forms carefully, and contact an attorney to confirm what action, if any, needs to be taken. Keep in mind that many of these forms include strict timelines that must be met.

Notice of Assignment of Independent Medical Review (IMR)

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The administrative director (AD) designated a company entitled Maximus to conduct all of the Independent Medical Reviews (IMR). Maximus must notify the parties in writing that the dispute has been assigned for review and will do so in a letter entitled Notice of Assignment (NOA).

The notification will generally provide that the parties have 15 calendar days (with some limited exceptions) to provide to Maximus, at a minimum, all medical reports issued in the prior six (6) months. Furthermore, the claims examiner must also forward the following:

  • A copy of the UR determination notifying the employee and the employee's treating physician that the requested medical treatment was denied, delayed or modified.
  • A copy of all information provided to the employee by the claims administrator concerning the UR decision regarding the disputed treatment.
  • A copy of any materials the employee or the employee's medical provider submitted to the claims administrator in support of the request for authorization of the disputed treatment.
  • A copy of any other relevant documents or information, including statements by the claims administrator explaining the reasons for the decision to deny.

IMR Notice of Assignment is detailed in Labor Code 4610 Regulation 9792.10.3 and 9792.10.4. Documentation is detailed in Labor Code 4610.5 Regulation 9792.10.5

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