Independent Medical Review (IMR) ApplicationDownload Form
It is required that this form be filled out, and sent to the injured worker with a Utilization Review denial letter. If an injured wishes to appeal a denial of medical treatment, then this form must be submitted within 30 days of the date of the utilization review denial letter.
The injured worker, their doctor, or their attorney can submit this Application. The administrative director (AD) designated a company entitled Maximus to conduct all of the Independent Medical Review (IMR).