Form Hcb 002P – Fill Out and Use This PDF

STATE OF CALIFORNIA

Dave Jones, Insurance Commissioner

DEPARTMENT OF INSURANCE

HEALTH CLAIMS BUREAU

300 SOUTH SPRING STREET, SOUTH TOWER LOS ANGELES, CA 90013 www.insurance.ca.gov

HCB-002P

Eff: 08/01/2011

APPLICATION FOR INDEPENDENT MEDICAL REVIEW

Please be aware that a copy of this Application for Independent Medical Review will be provided to the insurance company. Also, please be advised that:

ｸA decision not to participate in the independent review process may cause the forfeiture of any statutory right to pursue legal action against the insurer regarding the disputed health care service.

ｸYour consent to obtain any necessary medical records from the insurer, any of its contracting providers, and any out- of-plan provider the insured may have consulted on the matter, is necessary to be signed by you.

ｸYou have the right to provide information or documentation, either directly or through your provider, regarding any of the following:

ｸThe provider’s recommendation indicating that the disputed health care service is medically necessary for the insured’s medical condition.

ｸMedical information or justification that a disputed health care service, on an urgent care or emergency basis, was medically necessary for the insured’s medical condition.

ｸReasonable information supporting your position that the disputed health care service is or was medically necessary for the medical condition, including all information provided to the insured by the insurer or any of its contracting providers, still in the possession of the insured, concerning an insurer or provider decision regarding disputed health care services, and a copy of any materials the insured submitted to the insurer, still in the possession of the insured, in support of the grievance, as well as any additional material that the insured believes is relevant.

1.Complete name of insurance company and policy/certificate number:

2.Claim number and date(s) of medical service(s):

3. Have you contacted the company to request an Independent Medical Review? Yes ___ No ___

(Provide copies of all correspondence)

4.___ If there is an imminent and serious threat to the health of the insured or claimant, please check and indicate the diagnosis.

5.Briefly describe the disputed medical service or expense that you want referred to the Independent Medical Review Organization and list the physicians who have treated you for this condition. Use additional paper as needed.

I hereby request Independent Medical Review of my dispute with the insurer. I authorize the release of any and all of my medical records and information, of any type, of or pertaining to the scope of this authorization including medical, mental health, substance abuse, HIV records, diagnostic imaging reports, and any other type of non-documentary records, as well as pertinent non-medical records and information. This authorizes release by and among all medical providers, the insurer, the California Department of Insurance and any Independent Medical Review Organization. Release and disclosure are authorized only to the extent any of those persons or entities may deem appropriate for a purpose consistent with the review of a complaint regarding health care services. This authorization will expire one year from the date below, except as regarding the Department’s internal use or as otherwise allowed by law. The expiration will apply to all information not previously released pursuant to this authorization. This authorization may be revoked or withdrawn at any time. A revocation or withdrawal will apply to all information not previously release pursuant to this authorization. I attest that the information provided is accurate and truthful

Signature

Date