QME Form Requests

Forms

Report Requests

Please submit the following information to request a copy of a report or status of a pending report:

Report Assistance(Required)

First Name

Last Name(Required)

Claim Number(Required)

Date of Report

Evaluation/Report Type(Required)

Full Name QME Physician(Required)

First Last

Notes

Submitter's Full Name(Required)

First Last

Submitter's Email(Required)

Medical Records

Please provide records and cover letters at least 2 weeks prior to the scheduled evaluation.

Our office accepts records electronically which can be uploaded to our website directly at https://expedientmedicolegal.com/upload-records/, or you may fax to (855) 329-0525.

Pursuant to the Labor Code §4062.3, all records that are to be reviewed must include an Attestation by the sending party with the correct and total amount of pages provided and signed under penalty of perjury. Please be advised, if an attestation is not received with the records, then the records will not be reviewed until the required Attestation is received. See CCR 9793(n) for the definition of “record review.”

Eval. Attendance Confirmation

Please submit the following information to request confirmation of an applicant’s attendance:

Applicant Full Name(Required)

First Last

Claim Number(Required)

Date of Evaluation(Required)

Evaluation Report Type(Required)

Physician QME(Required)

First Last

Submitter's Full Name(Required)

First Last

Submitter's Email(Required)

Notes

Billing & Collections

Billing and Collections

For any questions regarding billing, collections, statements, or payments, please provide the following information:

Applicant Full Name(Required)

First Last

Claim Number(Required)

Date of Evaluation(Required)

Evaluation/Report Type(Required)

Physician QME(Required)

First Last

Submitter's Full Name(Required)

First Last

Submitters Email(Required)

Notes

Evaluation Request Status

Regarding status of scheduling an evaluation or deposition; or to reschedule or cancel an evaluation or deposition, please submit the below information:

Date of Initial Request(Required)

Applicant Full Name(Required)

First Last

Claim Number(Required)

Evaluation / Report Type(Required)

Physician QME(Required)

First Last

Submitter's Full Name(Required)

First Last

Submitters Email(Required)

Notes

QME Form Requests

Forms

Report Requests

Please submit the following information to request a copy of a report or status of a pending report:

Eval. Attendance Confirmation

Please submit the following information to request confirmation of an applicant’s attendance:

Billing and Collections

For any questions regarding billing, collections, statements, or payments, please provide the following information:

Evaluation Request Status

Regarding status of scheduling an evaluation or deposition; or to reschedule or cancel an evaluation or deposition, please submit the below information:

Contact Us

Services

Get Started