What this form is for
Independent medical review application * For injured workers who need to get an independent medical review
Official file
Published by the Division of Workers' Compensation. This page does not replace the form — it points at the state's PDF and, where the form is what a panel actually ruled on, quotes that ruling.
How to fill a DWC form →Source: dir.ca.gov/dwc/forms.html. Unofficial guide — the PDF on that site is the form.
What the Appeals Board did with this
Decisions of the Workers' Compensation Appeals Board that turned on this kind of filing. Each quotes the passage it turned on and links to the official PDF.
- ADJ10412642 · 2026-10-06 · Fresno District OfficeMedical treatment / UR / IMRdefendant prevailed
Determinative passage · p.8In declining to permit Dr. Bonin’s report or Dr. Chauhan’s supplemental report to be sent to the QME, the WCJ explained in the Report as follows: Bonin’s report was not a neutral factual record. It was a retained biomechanical opinion that directly critiqued QME Dr. Hill’s causation analysis and extended into medical causation. (Defendant’s Exhibits A and B.)
The WCJ and WCAB found that Dr. Bonin's biomechanical report and Dr. Chauhan's supplemental report were not substantial medical evidence and should not be sent to the QME for review and comment because they were either nonmedical information or speculative and derivative medical opinions.
Official decision · page 8 → - ADJ11249966 · 2026-10-02 · Anaheim District OfficeMedical treatment / UR / IMRapplicant prevailed
Determinative passage · p.8pursuant to section 4622(a)(1), defendant is automatically liable for payment of penalties and interest. Moreover, if a defendant does not pay a proper medical-legal invoice in full or fails to provide an EOR within the 60-day window, then a defendant has waived all objections to the medical-legal provider’s billing except compliance with sections 4620 and 4621. (Cal. Code Regs., tit. 8, § 10786(e); see Colamonico, supra.) Consequently, even if defendant here had successfully showed that section 5307.9 applied, it had already waived this defense when it failed to comply with section 4622(a)(1). Accordingly, we rescind the F&O and substitute new Findings that find that section 5307.9 does not apply in this matter; defendant failed to issue EOBs or any payment to cost petitioner within 60 days; cost petitioner met its burden under sections 4620, 4621, and 4622; and defendant is liable for payment of penalties and interest under section 4622(a)(1). We defer the issue of attorney’s fees and costs and return the matter to the WCJ so that the WCJ may consider the issue in the first instance. For the foregoing reasons, IT IS ORDERED as the Decision After Reconsideration of the Workers’ Compensation Appeals Board that the January 20, 2022 Findings of Fact is RESCINDED and the following is SUBSTITUTED therefor:
The WCAB found that Labor Code section 5307.9 does not apply, defendant failed to issue Explanations of Benefits or payment within 60 days, cost petitioner met burden under sections 4620, 4621, and 4622, and defendant is liable for penalties and interest under section 4622(a)(1).
Official decision · page 8 → - ADJ3117080 · 2026-09-28 · Sacramento District OfficeMedical treatment / UR / IMRapplicant prevailed
Determinative passage · p.7Here, the applicant’s QME panel request failed to comply with the statutory requirements described above. It is unclear from the record how the panel was obtained. Specifically, although validity of QME panel number 3686064 was at issue for trial, there is no evidence that either party objected to a medical determination by a treating physician within 30 days, or any agreed upon time extension, from the receipt of any treating physician report in compliance with section 4062(a). (Lab. Code, § 4062(a).) Furthermore, there is no evidence in the record that the defendant provided a form to applicant to request a panel QME within 10 days per section 4062.1(b). (Lab. Code, § 4062.1(b).) The WCJ found that QME panel number 3686064 was valid based on the August 5, 2025, Stipulation and Order that states: THE QME APPOINTMENT WITH DR. WIESELTIER SET FOR 8/14/25 WILL BE CANCELLED PENDING DETERMINATION BY THE WCAB ON WHETHER THE QME PANEL IS APPROPRIATE. IF THE PANEL IS DETERMINED APPROPRIATE A QME APPOINTMENT WILL BE RESCHEDULED AS APPROPRIATE. (All capitals in original.)
The QME panel was found invalid because the statutory requirements for obtaining the panel were not met, including lack of timely objection and failure to provide the panel request form to the applicant.
Official decision · page 7 → - ADJ11672907 · 2026-09-24 · Salinas District OfficeMedical treatment / UR / IMRapplicant prevailed
Determinative passage · p.11Taking all the above into consideration and given that the medical record is lacking with respect to the issue of applicant’s psyche claim, we continue to believe that good cause exists for the issuance of an additional QME panel.
The medical record was insufficient on the psyche claim, and Dr. Feinberg, the orthopedic AME, recommended a psyche evaluation. The WCAB found good cause for an additional QME panel to address the psyche claim.
Official decision · page 11 →