(English source text)
Requesting an Independent Medical Review
If you dispute either the diagnostic service, diagnosis or treatment prescribed by the third opinion physician, you may request an Independent Medical Review by filing the completed Independent Medical Review Application form with the Division of Workers’ Compensation (DWC) Administrative Director.
When you request a third opinion, REM, LTD will send you an Independent Medical Review Application form with the “MPN Contact” section completed. To request an Independent Medical Review:
- Complete the “Employee” section of the form.
- Indicate on the form whether you are requesting a in-person examination or records review.
- List an alternative specialty, if any, that is different than the specialty of the treating physician.
- Send the completed form to the DWC Administrative Director at the address noted on the form.
Within 10 business days of receiving the form, the DWC Administrative Director will select an Independent Medical Reviewer (IMR) with an appropriate specialty and send written notification of the name and contact information of the IMR.
You have 10 calendar days from the receipt of the name of the IMR to object to the selection if there is a conflict of interest or the IMR may withdraw within 10 calendar days of the receipt of the notification of selection. If this conflict is verified or the IMR withdraws, the DWC Administrative Director will select another IMR from the same specialty. If there are no available physicians with the same specialty, the DWC Administrative Director may select an IMR with another specialty based on the information submitted.
If you request an in-person exam, within 60 calendar days of receiving the name of the IMR, you must contact the IMR to arrange an appointment. If you do not contact the IMR for an appointment with you within 60 days calendar days of receiving the name of the IMR, then you will be deemed to have waived the IMR process with regard to this disputed diagnosis or treatment of this treating physician.
Once you contact the IMR, he/she will schedule an appointment with you within 30 calendar days of the request for an appointment, unless all parties agree to a later date. The IMR will notify the named MPN contact of the appointment date.
During this process, you must continue to treat with your treating physician or a physician of you r choice within the Intracorp MPN.
You must provide written notice to the DWC Administrative Director and the MPN Contact if you decide to withdraw the request for an Independent Medical Review.
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[Traditional Chinese target translation]
申請獨立醫學審查
如果您對於第三位醫生的診斷服務、診斷或治療仍然持有異議，您可以向勞工補償處（DWC）的行政主管索取並填寫“獨立醫學審查申請表”，從而申請進行獨立醫學審查。
當您申請第三位醫生時，REM，LTD 將寄給您一張“獨立醫療審查申請表”，其中“MPN 聯繫人”一欄已經填好。申請獨立醫學審查：
- 填寫表格中的“雇員”一欄。
- 在表格中注明，您是申請現場檢查，還是病歷審查。
- 列出與現任醫生的專業不同的其他專業（如果有）。
- 按照表格上注明的地址，將填寫好的表格寄給 DWC 行政主管。
DWC 行政主管收到表格後，將在 10 個工作日內選擇一位懂得相關專業的獨立醫學審查員（IMR），並以書面方式將 IMR 的姓名和聯繫方式通知您。
如果存在利益衝突，您可以在收到 IMR 姓名後的 10 個日曆日內拒絕該選擇，IMR 也可以在收到選擇通知後的 10 個日曆日內退出。如果利益衝突確實存在或者 IMR 退出，DWC 行政主管將另選一位懂得相同專業的 IMR。如果找不到懂得相同專業的醫生，DWC 行政主管將根據提交的信息，選擇一位懂得其他專業的 IMR。
如果您申請現場檢查，則必須在收到 IMR 姓名後的 60 日內與 IMR 聯繫並安排預約。如果您在收到 IMR 姓名後的 60 日內未聯繫 IMR 並預約時間，將視爲您已放棄就此位診療醫生的此次有爭議的診斷或治療而申請的 IMR 程序。
一旦您聯繫 IMR 並請求預約時間，他/她將在收到請求後的 30 個日曆日內爲您安排一個時間，除非各方均同意延期。IMR 將告訴您預約之日指定的 MPN 聯繫人。WWWWWW
在此過程中，您必須繼續接受現任醫生或您選擇的 Intracorp MPN 醫生的治療。
如果您決定撤銷獨立醫學審查申請，則必須以書面方式通知 DWC 行政主管及 MPN 聯繫人。