Application for Independent Medical Review

When to Use This Form

File this form to request an Independent Medical Review (IMR) when a utilization review decision denies or modifies medical treatment.

Download DWC-AD 10133.55

PDF download will be available once the form is uploaded to our CMS.

Need Help Filing Your DWC-AD 10133.55?

Our attorneys can guide you through the process and ensure your claim is filed correctly.