"Independent Medical Review (Imr) Request Form" - Montana

Independent Medical Review (Imr) Request Form is a legal document that was released by the Montana Department of Labor and Industry - a government authority operating within Montana.

Form Details:

  • The latest edition currently provided by the Montana Department of Labor and Industry;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the Montana Department of Labor and Industry.

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Independent Medical Review (IMR)
Request Form
Date Received by the Department
Date Submitted:
Date of Birth
(For Department use only)
(MM/DD/YYYY)
(MM/DD/YYYY)
Claimant Name:
Date of MMI
Claim Administrator Claim No.:
Date of Injury:
if rendered:
(MM/DD/YYYY)
(MM/DD/YYYY)
Parts of Body Injured:
Petitioner Name:
Address/City/State/Zip:
Phone:
Relationship to Claimant:
Insurer Name:
(if not the person submitting the request)
Address/City/State/Zip:
Phone:
Treating Physician Name:
(if not the person submitting the request)
Address/City/State/Zip:
Phone:
Contact Person:
Request being submitted by:
Treating Physician
Referred Physician
Preliminary diagnosis:
Subsequent diagnosis:
What is the nature of your dispute?
What procedure or treatment are you requesting the Medical Director to review?
Was your request for prior authorization of this procedure denied by the insurer?
What attempt have you made to resolve your dispute?
What documentation have you submitted in support of your request?
(Please list and provide a copy of medical records to support your Medical Review request.)
Independent Medical Review (IMR)
Request Form
Date Received by the Department
Date Submitted:
Date of Birth
(For Department use only)
(MM/DD/YYYY)
(MM/DD/YYYY)
Claimant Name:
Date of MMI
Claim Administrator Claim No.:
Date of Injury:
if rendered:
(MM/DD/YYYY)
(MM/DD/YYYY)
Parts of Body Injured:
Petitioner Name:
Address/City/State/Zip:
Phone:
Relationship to Claimant:
Insurer Name:
(if not the person submitting the request)
Address/City/State/Zip:
Phone:
Treating Physician Name:
(if not the person submitting the request)
Address/City/State/Zip:
Phone:
Contact Person:
Request being submitted by:
Treating Physician
Referred Physician
Preliminary diagnosis:
Subsequent diagnosis:
What is the nature of your dispute?
What procedure or treatment are you requesting the Medical Director to review?
Was your request for prior authorization of this procedure denied by the insurer?
What attempt have you made to resolve your dispute?
What documentation have you submitted in support of your request?
(Please list and provide a copy of medical records to support your Medical Review request.)