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Consultative Rating Request DIA-11 - California
|Consultative Rating Request Form. This is a California form and can be used in General Workers Comp .||
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CONSULTATIVE RATING REQUEST TO: DISABILITY EVALUATION UNIT: DATE OF REQUEST: A CONSULTATIVE EVALUATION OF THE ATTACHED MEDICAL REPORT(S) IS REQUESTED BASED ON THE FOLLOWING. 1. 2. 3. 4. 5. 6. Name of Injured Worker: WCAB Case Number: Social Security Number: Occupation*: Date of Injury: Date of Birth: * If occupation is questionable, attach a job description. JUDGE: APPLICANT ATTORNEY: DEFENDANT: CONSULTATIVE RATINGS WILL BE PROVIDED ONLY ON THE FOLLOWING: medical reports; (2) When this is a substantial likelihood the estimate (to avoid abuse, this will be monitored by the Presiding Judge); (3) On or a jointly signed request of both parties when a Declaration of Readiness 9758). PLEASE LEGIBLE ENCLOSE TWO SELF-ADDRESSED STAMPED PHOTOCOPIES OF MEDICAL REPORTS. ENVELOPES (1) Agreed or Independent will result in settlement the request of a W.C.J. has been filed (AD Rule FOR SERVICE AND Joint request for consultative rating of a single medical report must be signed by both sides. Parties will be served according to submitted pre-addressed stamped envelopes. ALL PHOTOSTATED MATERIAL SUBMITTED WILL BE DESTROYED - RETAIN YOUR ORIGINAL COPY . . . Division of Workers' Compensation Office of Benefit Determination - DEU 2550 Mariposa Street, Room 3014 Fresno, CA 93721-2280 DIA-11 2002 © American LegalNet, Inc.