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I.

MM slash DD slash YYYY
Mailing Address*

III.

Mailing Address

IV.

Mailing Address

V.

VI.

VII.

VIII.

IX.

( Weekly / Monthly Salary of Hourly Rates & Hours Worked per Week )
Do you work overtime?

X.

Any Time Lost from Work?

XI.

Any Compensation Paid?

XII.

Unemployment Compensation?

XIII.

Medical Treatment Received?
Was All Treatment Furnished by Employer or Workers' Comp. Insurance Carrier?
Did Medi-Cal Pay for any Treatment?

XIV.

Is there Any Current Dispute in your Case Regarding Medical Treatment, Temporary Disability, Permanent Disability, Vocational Rehabilitation?

XV.

Have you Received a Form from your Employer or Insurance Carrier Requesting a Panel of Doctors (a "QME Panel")?

XVI.

Have you Received a List of Three (3) Doctors from the State, or from the Department of Workers' Compensation?

XVII.

Have you Responded to Any Written Submission Made to You?

XVIII.

Have you been Notified of an Upcoming Medical Exam?
Have you Already Attended a Medical Exam at the Request of your Employer or Insurance Carrier?

XIX.

???Did Treater State Injury is Work Related?
At Least 51% Work Related?

XX.

Have You Ever Filed a Workers' Compensation Case?

XXI.

ADDITIONAL INFORMATION