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About Us
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Contact
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Upload Records
Schedule an Evaluation
Schedule an Evaluation
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Schedule an Evaluation
1
General Information
2
Evaluation Details
3
Submission
Type of Evaluation/Service Requested
*
QME Panel
Agreed Medical Evaluation
Qualified Medical Evaluation (unrepresented applicant)
Independent Medical Examination
Disability Evaluation
Fitness for Duty Evaluation
Other
Initial Evaluation
Reevaluation
QME/AME Physician
Location of Evaluation
Please Select
Other - Specify Below
Anaheim
Antioch
Bakersfield
Chino
Costa Mesa
El Cerrito
Fresno
La Mirada
La Palma
Lancaster
Lodi
Long Beach
Los Angeles
Manteca
Merced
Modesto
North Hollywood
Orange
Oxnard
Palmdale
Pasadena
Pleasanton
Riverside
San Bernardino
San Diego
San Pedro
Stockton
Torrance/Gardena
Visalia
Whittier
Location (Other)
APPLICANT/CLAIMANT/WORKER INFORMATION
Applicant Name
First
Last
Applicant Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Applicant Phone Number
Applicant Email
Home
Cell
Secondary Phone Number
Home
Cell
Applicant SSN
Applicant Date of Birth
Month
Day
Year
Specific Date(s) of Injury
Continuous Trauma Dates of Injury
Panel Number
Workers’ Compensation Carrier Insurance Claim No.
ADJ/EAMS Number
Is televideo acceptable?
Yes - televideo is allowed
No - televideo is not allowed (in person only)
INTERPRETER
Interpreter Required?
Yes
No
Language
Please specify, if other than English.
Interpreter Name/Company
State Certified Identification Number for interpreter
Interpreter Phone Number
EMPLOYER INFORMATION
Employer
WORKERS’ COMPENSATION CARRIER INFORMATION/BILLING INFORMATION
Insurance Company
Mailing Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Adjuster:
Adjuster Name
Adjuster Email
Adjuster Phone Number
Adjuster Fax Number
ATTORNEY INFORMATION
Applicant Attorney
Applicant Attorney Name
Applicant Attorney Law Firm
Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Address (If first address is a PO Box)
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Applicant Attorney Phone Number
Applicant Attorney Fax Number
Defense Attorney
Defense Attorney Name
Defense Attorney Law Firm
Address
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Defense Attorney Phone Number
Defense Attorney Fax Number
PERSON PROVIDING THIS INFORMATION
Name
First
Last
Phone
Email
Affiliation of the provider of this information
Affiliation of the provider of this information
Applicant Attorney's Office
Defense Attorney's Office
Insurance/Claims Adjuster
I am the injured worker
Email
This field is for validation purposes and should be left unchanged.