Form I&A19 "Information & Assistance Unit Guide - How to File a Petition Appealing Administrative Director's Independent Medical Review Determination" - California

What Is Form I&A19?

This is a legal form that was released by the California Department of Industrial Relations - Division of Workers' Compensation - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on June 1, 2018;
  • The latest edition provided by the California Department of Industrial Relations - Division of Workers' Compensation;
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  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form I&A19 by clicking the link below or browse more documents and templates provided by the California Department of Industrial Relations - Division of Workers' Compensation.

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Information & Assistance Unit Guide 19
How to file a petition appealing administrative director’s
independent medical review determination
If you disagree with either a medical treatment determination made through the
independent medical review (IMR) process or a decision from the Administrative
Director (AD) denying your application for IMR, you must file a petition (appeal) in
order to challenge it. To do this, you may use the attached form.
The Labor Code requires that you file the petition with your local district office of
the Division of Workers’ Compensation (DWC) within 30 days from the date the
determination or decision was mailed, but if it was mailed in California, the time to
file is extended to 35 days. You will find the date that the medical treatment
determination was mailed on the first page of the IMR decision. The date the
decision denying your application for IMR was mailed can be found near the AD’s
signature or on the accompanying proof of service.
There are only five allowable reasons for appealing the IMR determination which
are listed on the attached form. Strike out any items that do not apply to your
case. Be sure to identify every item that you disagree with and include a full
explanation. You may attach more sheets of paper if needed.
Please note that all forms must be typed or handwritten in block letters to insure
legibility. Fill out the form completely and be sure to sign and date the form.
Send copy of your petition to your local district office:
https://www.dir.ca.gov/dwc/dir2.htm. You must also send a copy to all the
parties including the DWC’s Independent Medical Review Unit at 1515 Clay St.,
18
th
Floor, Oakland, CA 94612.
If the WCAB reverses the independent medical review determination, your medical
treatment issues will be sent to another independent medical reviewer for review.
Submit the following documents with your form filing in the order shown:
Document Cover Sheet
Document Separator Sheet (for Appeal of Determination of AD-IMR)
Petition Appealing Administrative Director’s Independent Medical
Review Determination
Verification
 Copy of the Administrative Director’s Independent Medical Review
Determination
Document Separator Sheet (for Proof of Service by Mail)
Proof of Service by Mail
I&A 19
Rev. 06/18
Information & Assistance Unit Guide 19
How to file a petition appealing administrative director’s
independent medical review determination
If you disagree with either a medical treatment determination made through the
independent medical review (IMR) process or a decision from the Administrative
Director (AD) denying your application for IMR, you must file a petition (appeal) in
order to challenge it. To do this, you may use the attached form.
The Labor Code requires that you file the petition with your local district office of
the Division of Workers’ Compensation (DWC) within 30 days from the date the
determination or decision was mailed, but if it was mailed in California, the time to
file is extended to 35 days. You will find the date that the medical treatment
determination was mailed on the first page of the IMR decision. The date the
decision denying your application for IMR was mailed can be found near the AD’s
signature or on the accompanying proof of service.
There are only five allowable reasons for appealing the IMR determination which
are listed on the attached form. Strike out any items that do not apply to your
case. Be sure to identify every item that you disagree with and include a full
explanation. You may attach more sheets of paper if needed.
Please note that all forms must be typed or handwritten in block letters to insure
legibility. Fill out the form completely and be sure to sign and date the form.
Send copy of your petition to your local district office:
https://www.dir.ca.gov/dwc/dir2.htm. You must also send a copy to all the
parties including the DWC’s Independent Medical Review Unit at 1515 Clay St.,
18
th
Floor, Oakland, CA 94612.
If the WCAB reverses the independent medical review determination, your medical
treatment issues will be sent to another independent medical reviewer for review.
Submit the following documents with your form filing in the order shown:
Document Cover Sheet
Document Separator Sheet (for Appeal of Determination of AD-IMR)
Petition Appealing Administrative Director’s Independent Medical
Review Determination
Verification
 Copy of the Administrative Director’s Independent Medical Review
Determination
Document Separator Sheet (for Proof of Service by Mail)
Proof of Service by Mail
I&A 19
Rev. 06/18
Information & Assistance Unit Guide 19
Keep copies of your filings for your records.
In order to have your petition addressed by a judge, you must also complete and file a
“Declaration of Readiness to Proceed” (DOR). For instructions on how to complete and file a
DOR, please see Information & Assistance (I&A) Guide No. 5:
https://www.dir.ca.gov/dwc/iwguides/IWGuide05.pdf. To request an expedited hearing, use
I&A Guide No. 6: http://www.dir.ca.gov/dwc/iwguides/IWGuide06.pdf. Either request for
hearing can be filed at the same time you file your petition or afterwards.
If you do not yet have an ADJ case number assigned, you will need to submit an “Application
for Adjudication of Claim” which opens a WCAB case for you. To do this, please see I&A
Guide No. 4: https://www.dir.ca.gov/dwc/iwguides/IWGuide04.pdf. If you already have an ADJ
case number assigned, you will not need to resubmit your “Application for Adjudication”.
All documents filed with the Division of Workers’ Compensation district office must include a
document cover sheet and a document separator sheet. Please see I&A Guide Nos. 17 and
18 to learn how to complete these forms. Additional form instructions can be found on the
EAMS OCR handbook at:
http://www.dir.ca.gov/dwc/eams/SampleFiles/EAMS_OCR%20handbook.pdf.
If you need help, call an Information and Assistance office, or attend a workshop for injured
workers. The local I&A phone numbers are attached to this guide. You can get information
on a local workshop from the I&A office or on the Web at www.dir.ca.gov/dwc.
The information contained in this guide is general in nature and is not intended as a substitute for legal
advice. Changes in the law or the specific facts of your case may result in legal interpretations different
than those present here.
When sending documents to a DWC District Office, please make sure they are not folded or stapled.
Send them in a large manila envelope. Please see the EAMS OCR handbook for further instructions.
I&A 19
Rev. 06/18
 
 
 
 
 
 
 
 
 
 
 
 
 
WORKERS’ COMPENSATION APPEALS BOARD DISTRICT OFFICES
ANAHEIM, 92806-2131
SACRAMENTO, 95834-2962
1065 North Link, Suite 170
160 Promenade Circle, Suite 300
Information & Assistance Unit (714) 414-1801
Information & Assistance Unit (916) 928-3158
BAKERSFIELD, 93301-1929
SALINAS, 93906-2204
th
1880 N Main Street, Suites 100 & 200
1800 30
Street, Suite 100
Information & Assistance (831) 443-3058
Information & Assistance Unit (661) 395-2514
EUREKA, 95501-0529 * Virtual office *
SAN BERNARDINO, 92401-1411
Information & Assistance Unit
464 W Fourth Street, Suite 239
Information & Assistance Unit (909) 383-4522
(707) 441-5723
FRESNO, 93721-2219
SAN DIEGO, 92108-4424
2550 Mariposa Street, Suite 4078
7575 Metropolitan Drive, Suite 202
Information & Assistance Unit (559) 445-5355
Information & Assistance Unit (619) 767-2082
LONG BEACH, 90810-1870
SAN FRANCISCO, 94102-7014
1500 Hughes Way, Suite C203
nd
455 Golden Gate Avenue, 2
Floor
Information & Assistance Unit (424) 450-2565
Information & Assistance Unit (415) 703-5020
LOS ANGELES, 90013-1105
SAN JOSE, 95113-1402
100 Paseo de San Antonio, Suite 241
th
th
320 W 4
Street, 9
Floor
Information & Assistance Unit (408) 277-1292
Information & Assistance Unit (213) 576-7389
MARINA DEL REY, 90292-6902
SAN LUIS OBISPO, 93401-8736
nd
rd
4740 Allene Way, Suite 100
4720 Lincoln Boulevard, 2
and 3
Floors
Information & Assistance Unit (805) 596-4159
Information & Assistance Unit (310) 482-3820
OAKLAND, 94612-1499
SANTA ANA, 92707-7704
th
2 MacArthur Place, Suite 600
1515 Clay Street, 6
Floor
Information & Assistance Unit (714) 942-7576
Information & Assistance Unit (510) 622-2861
OXNARD, 93030-7912
SANTA BARBARA, 93101-7538 * Satellite office *
1901 N Rice Avenue, Suite 100
130 E Ortega Street
Information & Assistance Unit (805) 485-3528
Information & Assistance Unit (805) 568-1390
POMONA, 91768-1653
SANTA ROSA, 95404-4771
732 Corporate Center Drive
50 “D” Street, Suite 420
Information & Assistance Unit (909) 623-8568
Information & Assistance Unit (707) 576-2452
REDDING, 96002-0940
STOCKTON, 95202-2314
nd
31 E Channel Street, Suite 344
250 Hemsted Drive, 2
Floor, Suite B
Information & Assistance Unit (209) 948-7980
Information & Assistance Unit (530) 225-2047
RIVERSIDE, 92501-3337
VAN NUYS, 91401-3370
3737 Main Street, Suite 300
6150 Van Nuys Boulevard, Suite 105
Information & Assistance Unit (951) 782-4347
Information & Assistance Unit (818) 901-5374
Rev. 07/21
STATE OF CALIFORNIA
DWC DISTRICT OFFICE
+
+
DOCUMENT COVERSHEET
Is this a new case?
Yes
D
No
D
Companion Cases Exist
D
Walkthrough
Yes
D
No
D
More than 15 Companion Cases
D
SSN:
Date:(MM/DD/YYYY)
D
Specific Injury
Case Number 1
D
Cumulative Injury
(Start Date: MM/DD/YYYY)
(End Date: MM/DD/YYYY)
(If Specific
Injury,
use the start date as the specific date of injury)
Body Part 1:
+
Body Part 3:
Body Part 2:
Body Part 4:
Other Body Parts:
Please check unit to be filed on ( check only one box )
D
ADJ
D
DEU
D
SIF
D
UEF
D
SAU
DINT
0RSU
Companion Cases
Case Number 2
D
Specific Injury
D
Cumulative Injury
(Start Date: MM/DD/YYYY)
(End Date: MM/DD/YYYY)
(If Specific
Injury,
use the start date as the specific date of injury)
Body Part 1:
Body Part 3:
Body Part 2:
Body Part 4:
Other Body Parts:
I
DWC-CA foITTl 10232.1 Rev. 5/2020 - Page 1 of 8
+
SAMPLE
YOUR SOCIAL
TODAY'S DATE
SECURITY NUMBER
DATE OF INJURY
EAMS CASE NUMBER
IF NEW CASE
LEAVE BLANK
USE CODE FROM
BODY PART CODE LIST --
SEE PAGE 8
WHEN MORE THAN 5 BODY PARTS USE BODY
PART NUMBER 700 IN THIS FIELD
 
 
 
 
   
       
 
District office codes for place of venue
Legend Abbreviation
Office
AHM
Anaheim
ANA
Santa Ana
BAK
Bakersfield
EUR
Eureka*
FRE
Fresno
LAO
Los Angeles
LBO
Long Beach
MDR
Marina del Rey
OAK
Oakland
OXN
Oxnard
POM
Pomona
RDG
Redding
RIV
Riverside
SAC
Sacramento
SAL
Salinas
SBA
Santa Barbara**
SBR
San Bernardino
SDO
San Diego
SFO
San Francisco
SJO
San Jose
SLO
San Luis Obispo
SRO
Santa Rosa
STK
Stockton
VNO
Van Nuys
* Eureka is a satellite office of Santa Rosa district office.
** Santa Barbara is a satellite office of Oxnard district office.
Use this document to complete forms,
but do not file this document with your forms.
DWC‐CA form 10232.1 Rev. 5/2020 – Page 7 of 8
Page of 12