Medical Examiner-Mental Health Expert Payment Voucher {RI-AD003}

SUPERIOR COURT OF CALIFORNIA, COUNTY OF RIVERSIDE MEDICAL EXAMINER/MENTAL HEALTH EXPERT PAYMENT VOUCHER INSTRUCTIONS The following instructions pertain to requests for payment of medical examiner and interpreter fees on court ordered medical examinations. Form must be typed Section A. General Information: 1. Complete the following information: a. b. c. d. The name, address, email and phone number of the claimant/vendor The case number, including the case prefix The defendant date of birth The defendant name Section B. Medical Examiners/Mental Health Expert 2. Complete the following information: a. b. c. The date of appointment, the name of the judicial officer who has made the appointment and the judicial officer's department. Specify the applicable code section authorizing the appointment (e.g., PC 1368/1369, PC 288.1, WIC 370, EC 1017, PC 1026, etc.). The date on which the examination or court testimony was performed and whether the testimony was for a full or half day. The attached invoice should include a full description of the services rendered on the specified dates. The authorized court approved fee for the examination ordered and conducted. Check the boxes as to supporting documentation and attach the documents as indicated. A copy of the Notice of Appointment, a billing invoice for requested fees and 3 copies of the completed report must be attached. The absence of required documents and/or incomplete information may result in return of the documents for completion. d. e. Section C. Interpreter/Other Services: 3. Complete the following information: a. b. c. d. Specify whether an interpreter was used or other services provided: The name of the interpreter: Costs for services ­ Interpreter: If the order for an interpreter is not included in the minutes (present on minute order), provide proof of the court's order. Section D. Verification: 4. Sign and date the payment voucher. Mail the completed payment voucher and all supporting documents to the Court who ordered the report. Note: Please include the case number on all inquiries and other correspondence Page 1 of 2 Adopted for Mandatory Use Riverside Superior Court RI-AD003-INFO [Rev. 10/21/15] MEDICAL EXAMINER/MENTAL HEALTH EXPERT PAYMENT VOUCHER riverside.courts.ca.gov.localfrms/localfrms.shtml American LegalNet, Inc. www.FormsWorkFlow.com SUPERIOR COURT OF CALIFORNIA, COUNTY OF RIVERSIDE RI-AD003 MEDICAL EXAMINER/MENTAL HEALTH EXPERT PAYMENT VOUCHER SECTION A. GENERAL INFORMATION Medical Examiner/Mental Health Expert Information Name: Address: City/State/Zip: Case No. (s): Defendant: SECTION B. MEDICAL EXAMINER/MENTAL HEALTH EXPERT Phone Number: Email Address: Date of Birth: Date Appointed: Appointed pursuant to code section: Date of: Exam By Judicial Officer: Other: Half day Minute Order attached Full day Department: Testimony Court approved fee: $ Notice of Appointment attached Invoice attached 3 copies ­ completed report attached (not applicable for EC 1017 evaluations) SECTION C. INTERPRETER/OTHER SERVICES Interpreter used Name of interpreter: Cost of services: $ Other (specify): If the order for an interpreter is not included in the minutes (present in the minute order), provide proof of the court's order SECTION D: I DECLARE THE FOREGOING AND ANY ATTACHMENTS HERETO TO BE AN ACCURATE STATEMENT OF SERVICES RENDERED IN THIS CASE. (SIGNATURE OF CLAIMANT) (DATE) For Court Use Only Fund: 110001 Cost Center: 335911 PECT/Functional Area: GL: 939003 Approvers Initials: Approvers Printed Name: Comments: 120009 1212 939009 Date: 1233 939017 1234 Page 2 of 2 Adopted for Mandatory Use Riverside Superior Court RI-AD003 [Rev. 10/21/15] MEDICAL EXAMINER/MENTAL HEALTH EXPERT PAYMENT VOUCHER riverside.courts.ca.gov.localfrms/localfrms.shtml American LegalNet, Inc. www.FormsWorkFlow.com