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CA Department of Insurance
CA Department of Insurance
CA Department of Insurance

Privacy Notice on Information Collection-Providers

(Request for Assistance Forms/Independent Medical Review Application)

*** This notice is provided pursuant to the Information Practices Act of 1977 (California Civil Code Section 1798.17) ***

Collection and Use of Personal Information

California Insurance Code Sections 12921 and 12921.1, and related statutes and regulations give the California Department of Insurance (CDI) and the Consumer Services Division the authority to regulate and investigate consumer complaints. The CDI uses your information to address complaints brought to the Department's attention.  Information is collected subject to limitations contained in the Information Practices Act of 1977, SAM 5300, et seq., SIMM 5305, et seq., and other applicable state and federal laws.

Providing Personal Information is Voluntary

You do not have to provide the personal information requested. However, if you do not wish to provide us the necessary information, we may not be able to investigate your complaint. When providing information or documents, please do not include un-requested personal information, such as Social Security Numbers, Driver's License Numbers, unnecessary health-related information, and credit card or financial information.

Information Provided to CDI Is Confidential

All information you provide to us during the investigation of your complaint will be treated as a confidential communication under California Insurance Code Section 12919.  We will not disclose any information to any person outside CDI, unless otherwise permitted or required by law.

Possible Disclosure of Personal Information

We may share your personal information with the insurance licensee and in the case of an Independent Medical Review with the Independent Medical Review Organization. We may also share your information with other government or regulatory agencies as permitted or required by law, or pursuant to Memorandum of Understanding.

Access to Your Information

You have the right to access records containing your personal information which are maintained by CDI.  To request access, contact: CDI Privacy Officer, Legal Branch, Government Law Bureau, 300 Capitol Mall, Sacramento, CA 95814, (916) 492-3500, or via email at

Department Privacy Policy

The California Department of Insurance has developed policies regarding the privacy of your information.







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