COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : STATE OF CALIFORNIA DEPARTMENT OF INDUSTRIAL RELATIONS INDUSTRIAL MEDICAL COUNCIL Plaintiff(s) P.O. Box 8888 San Francisco, CA 94128-8888 -againstTel: (650) 737-2700 or 1-(800) 794-6900 Fax: (650) 737-2711 Index No. : ARNOLD SCHWARZENEGGER, GOVERNOR Calendar No. : : : JUDICIAL SUBPOENA Fee Period: : - License Defendant(s) Number: : ...................................................... Dear Dr. : THE PEOPLE OF THE STATE OF NEW YORK Pursuant to Labor Code § 139.2(n) and 8 CCR, § 18, the Industrial Medical Council requires all physicians TO appointed or reappointed as Qualified Medical Evaluators (QMEs) to pay an annual fee. The QME fee is non-refundable. $250 FEE GREETINGS: QMEs who have conducted 25 or more comprehensive medical - legal evaluations in the twelve months prior WE COMMAND evaluations performed as a Qualified Medical Evaluator, Agreed Medical Evaluator, to assessment of the fee. AllYOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable Medical Evaluator must be countedat the purpose of fee assessment (8 CCR §§ 16, 17). Court and Independent for the located at County of in room , on the day of , 20 , at o'clock in the noon, and at any recessed $125 FEE or adjourned date, to testify and give evidence as a witness in this action on the part of the QMEs who have conducted 11-24 comprehensive medical legal evaluations in the twelve months prior to assessment of the fee. All evaluations performed as a Qualified Medical Evaluator, Agreed Medical Evaluator, and Independent Medical comply with this subpoena forpunishable as a fee assessment (8 CCRwill 16, 17). liable to Your failure to Evaluator must be counted is the purpose of contempt of court and §§ make you the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a $110 FEE result of your failure to comply. QMEs who have conducted 0-10 comprehensive medical legal evaluations in the twelve months prior to Witness, Honorable , one of Agreed Medical Evaluator, assessment of the fee. All evaluations performed as a Qualified Medical Evaluator, the Justices of the Court in County, day of , 20 and Independent Medical Evaluator must be counted for the purpose of fee assessment (8 CCR §§ 16, 17). ADDITIONAL LOCATIONS (Attorney must sign above and type name below) QMEs who perform evaluations at more than one medical office location are required to pay an additional $100 per location (8 CCR, § 17). Misrepresentation of the number of evaluations performed or the number of additional locations shall constitute grounds for disciplinary proceedings (8 CCR, § 60). Attorney(s) for Office and Department of Industrial Relations P.O. Address Industrial Medical Council Location Fee Calculation Worksheet No.: Telephone Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com QME Fee Assessment Form 103 Rev. 9.00 COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : : Plaintiff(s) -against License Number: Index No. Calendar No. : : : : JUDICIAL SUBPOENA Defendant(s) : . . City, . . . . . . . . . . . . . . . . . Street, . . . . .State,.Zip. Code,. Phone .No.. . . . . . . . . . . . . . . . . . . . . . . . . . THE PEOPLE OF THE STATE OF NEW YORK TO Enter total Number of ALL location boxes checked GREETINGS: --> WE COMMAND YOU, that all business and excuses being laidPHYSICIAN. each of you attend before THIS SECTION MUST BE COMPLETED BY THE aside, you and , the Honorable at the Court located at County of those more medical/legalnoon, and at any recessed evaluations. in room $250.00 Primary fee for day ofphysicians who have ,done 25 or o'clock in the , on the , 20 at or adjourned date, to testify and give evidence as a witness in this action on the part of the $125.00 Primary fee for those physicians who have done 11-24 medical/legal evaluations. Your failure to comply those physicians who punishable as a contempt of evaluations. $110.00 Primary fee for with this subpoena is have done 0-10 medical/legalcourt and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply. $100.00 for each additional location(s). Witness, Honorable , one of the Justices of the Based on the amount of primary fee I have paid, I hereby declare under penalty of perjury under the laws Court in County, day of , 20 of the State of California that the foregoing is true and correct. Physician's Signature (Attorney must sign above and type name below) Date Attorney(s) for RETURN THIS FORM WITH YOUR CHECK PAYABLE TO: IMC QME PROCESSING P.O. BOX 8888 Office and P.O. Address SAN FRANCISCO, CA 94128-8888 QME Fee Assessment Form 103 Rev. 9.00 Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com
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