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Mandatory Declaration by Provider of Records
for Medical-Legal Examination
Information
Applicant Name
(Required)
First
Middle
Last
Employer
(Required)
AME / QME Name
(Required)
Evaluation Type
(Required)
Please Select
AME
QME
Date of Injury (DOI)
MM slash DD slash YYYY
Appointment Date
MM slash DD slash YYYY
Appointment Time
Hours
:
Minutes
AM
PM
AM/PM
Attestation
Your Name
(Required)
First
Last
Your Email
(Required)
I, declare under penalty of perjury under the laws of the State of California that I have complied with the provisions of Labor Code §4062.3 prior to providing these records to the Physician for the above-referenced injured worker and evaluation.
Signature
(Required)
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CCR 9793(n) “Record Review” means the review by a physician of documents sent to the physician in connection with a medical-legal evaluation or request for a report. The documents may consist of records, legal transcriptions, medical test results, and or other relevant documents. For purposes of record review, a page is defined as an 8 ½ x 11 single-sided document, chart or paper, whether in physical or electronic form. Multiple condensed pages or documents placed on a single page shall be charged as separate pages. Any documents sent to the physician for record review must be accompanied by a declaration under penalty of perjury that the provider of the documents has complied with the provisions of Labor Code §4062.3 before providing the documents to the physician. The declaration must also contain an attestation as to the total page count of the documents provided. A physician may not bill for review of documents that are not provided with this accompanying required declaration from the document provider. Any documents that are sent to the physician without the required declaration and attestation shall not be considered available to the physician or received by the physician for purposes of any regulatory or statutory duty of the physician records and report writing.
Document Upload
I attest that the number of pages (including cover letters and all other correspondence with attestation) provided to the Physician are:
No. of pages
(Required)
Cover Letter Upload
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Max. file size: 1 GB.
Medical Records Upload
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Max. file size: 1 GB.
Additional Files Upload
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Max. file size: 1 GB.
Attestation Upload
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Max. file size: 1 GB.
