Scheduling Portal

Scheduling Request Form
Appointment Type*
Evaluation Type*
Strike Panel Number:
Applicant's Full Name*

First NameLast Name
Applicant's Phone Number*
Other Phone Number
Alternative Phone Number
Applicant's Email Address
example@gmail.com
Applicant's Mailing Address*

Street Address

Street Address Line 2

CityState

Zip Code
Gender?
Applicant's Date Of Birth*

MonthDayYear
Date
Claim Number:
Is the applicant Represented or Unrepresented? *
What is the preferred language?
Will Applicant need an interpreter? (Yes/No)*

YesNo
Interpreting Company:
Phone Number

Evaluation Information
Evaluation Preference
Who is requesting this evaluation?
Other - Specify*
Who should we contact and coordinate the details of this evaluation with?*

First NameLast Name
Phone Number*
Email*
example@example.com
Evaluation Date Preference*

Next 20 daysNext 60 daysNext 90 daysEarliest AvailableOther
Evaluation Time Preference*
QME Physician - Full Name*
Example: Dr. John Smith Doe
Injured Body Part/s*

Insurance Adjuster Information
Insurance Adjuster Information
Adjuster's Full Name*

First NameLast Name
Name of Insurance Company*
Email Address*
example@example.com
Phone Number*
Ext
Insurance Adjuster Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Applicant Attorney Information
Applicant Attorney Information
First and Last Name

First NameLast Name
Law Firm Name (AA)
Email Address
example@company.com
Phone Number
Ext
Attorney Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Defense Attorney Information
Defense Attorney Information
First and Last Name

First NameLast Name
Law Firm Name (DA)
Email Address
example@company.com
Phone Number
Ext
Defense Attorney Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Upload Information
To submit medical records please use our Uploads Portal: www.calmedeval.com/upload
Strike Panel

Browse Files
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1. File Upload
Browse Files

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2. File Upload
Browse Files

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3. File Upload
Browse Files

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Electronic Service of Medical-Legal Reports by Medical Evaluators

Regulation §36.7.

https://www.dir.ca.gov/t8/36_7.html

Per title 8 CCR §36.7. Electronic Service of Medical-Legal Reports by Medical Evaluators we kindly request that all parties agree to electronic services of the ANF, Med-Legal Report and Invoice. This will ensure a faster delivery to all parties.

For purposes of electronic service of all medical-legal reports, the mandatory form 122 (AME or QME Declaration of Service of Medical-Legal Report, see 8 Cal. Code Regs. § 122) may be replaced by an Affidavit of Proof of Electronic Service. The Affidavit of Proof of Electronic Service shall set forth the exact title of the document served in the action, showing (A) the name and residence or business address of the person making the service, (B) that he or she is a resident of, or employed in, the county where the electronic service occurs, (C) that he or she is over the age of 18 years, (D) that he or she is readily familiar with the business' practice for serving electronically, and (E) that the document would be electronically served that same day in the ordinary course of business following ordinary business practices. The Affidavit of Proof of Electronic Service shall be signed under penalty of perjury under the laws of the State of California. The Affidavit of Proof of Electronic Service shall also include all of the following:

(1) The electronic service address and the residence or business address of the person making the electronic service.

(2) The date of electronic service.

(3) The name and electronic service address of the person or entity served.

(4) A statement that the document was served electronically.
Electronic Signature

Clear
Signer Information
Should be Empty:

Scheduling Request Form

Insurance Adjuster Information

Applicant Attorney Information

Defense Attorney Information

Electronic Service of Medical-Legal Reports by Medical Evaluators