Treating/Consult Appointment Request

Please fill in all applicable information for your case. To submit the information to our office, you must either choose to “print” or “email” the form.

To submit your information via fax , please select “Print Preview” and print out the form. Then, fax the completed form to: 714.755.0224, ATTN: Front Office Staff.

To submit your information via email , please select “Email Us” and the form will be emailed to our staff.

We will contact you with an appointment within 24 hours of receipt of the information. Thank you!

Appointment Form : TREATING

CLAIM INFORMATION
Intake Date
When is the report due?
How soon is the appointment needed?
Where would you like the appointment to be scheduled?
What type of exam?
This Claim Is
What is the Date of Knowledge?
What is the Date of Injury?
Employer
Describe the Nature of the Injury in Detail. (150 Characters only)
Is Modified Work Available to the Injured Worker?
PATIENT INFORMATION
Patient Name First Name:   Last Name:
Patient Address
Street Address:
Apartment Number:
City:
State:
Zip Code:
Patient Home Telephone Number
Patient Work Telephone Number
Patient Social Security Number
Claim Number
Date of Birth
APPLICANT ATTORNEY INFORMATION (Fill in if applicable.)
Applicant Attorney Firm Name
Applicant Attorney Address
Street Address:
City:
State:
Zip Code:

Applicant Attorney Telephone Number

Fax Number
WCAB #
DEFENSE ATTORNEY INFORMATION (Fill in if applicable.)

Defense Attorney Firm Name

Defense Attorney Address

Street Address:
City:
State:
Zip Code:

Defense Attorney Telephone Number

Fax Number
WCAB #
CLAIMS ADMINISTRATION INFORMATION

Your Name

First Name:   Last Name:

Your Company

Company Address

Street Address:
City:
State:
Zip Code:
Your Email Address

Your Telephone Number

Your Fax Number

Adjustor or Claims Examiner on Case

First Name:   Last Name:

Adjustor or Claims Examiner’s Telephone Number

Nurse Case Manager on Case

First Name:   Last Name:

Nurse Case Manager’s Telephone Number

Describe Utilization Review Process (150 Characters only)
Utilization Review Telephone Number

This evaluation may require a report over six pages. Do we have permission to bill for a report longer than six pages?

Will the doctor be addressing any medical legal issues?

Will you send a cover letter?

Will you send all applicable medical records?

Will the patient need an interpreter?

If an interpreter is needed, would you like us to schedule an interpreter?

Interpreter Company
Interp. Telephone Number
If yes, what language?

Special Instructions (300 Characters only)