DWC Form 9768.10
Independent Medical Review Application
(Division of Workers’ Compensation – 8 CCR §9768.10 Mandatory Form)
Employee Section: The Employee shall complete this section and send the completed form to the Administrative Director.
Mailing address: Dept. of Industrial Relations, Division of Workers’ Compensation, P.O. Box 71010, Oakland, CA 94612.
Employee Phone Number / Fax Employee’s Address
Employee’s Attorney’s Name, if applicable
Attorney’s Phone Number / Fax
Pursuant to Labor Code section 4616.4, I request that the Administrative Director set an Independent Medical Review
within 30 days from receipt of this Application.
Check one: Request for In-Person Examination Request for Record Review (no In-Person Examination)
Is interpreter needed for exam? ______ If yes, language:__________________________________________________________
Describe diagnosis and part of body affected:___________________________________________________________________________
Reason for request for Independent Medical Review. Please explain if the dispute involves the diagnosis, treatment or a test
(attach additional page or additional materials, such as medical records, if necessary):
Select an alternative specialty, other than specialty of treating physician, if any, from the list on the instructions for this form: