Department of Labor and Industry

Independent Medical Review Form

Independent Medical Review Request Form

The Independent Medical Review Request Form is currently available in an Adobe PDF file for downloading and printing. To return the form, you may:

  • Scan and return by e-mail to:·mlytle@mt.gov
  • Fax the form to:  Employment Relations Divison, ATTN:  Maralyn Lytle, 406-444-7710
  • Mail the form to:  Employment Relations Division, ATTN:  Maralyn Lytle, PO Box 8011, Helena, MT  59604

  

Questions?  E-mail Maralyn or call her at 406-444-6604

Download the form here:

Independent Medical Review Request Form

 

ePass Montana is a convenient and secure way to send Medical Records with the Independent Medical Review Request.

Go to this link, https://app.mt.gov/epass/epass,  to set up an ePass Montana account and bookmark it in your favorites.  ePass Montana is for State of Montana Business only.  Using the File Transfer Service, send all documents to the following email address:   mlytle@mt.gov