Document Upload Form

Document Upload Form
Name of Person Submitting Form*

First NameLast Name
Date of Submission*

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Date
Email Address*
example@example.com
Relationship to Applicant*
Applicant Name*

First NameLast Name
Claim Number*
Name of QME/AME*
Specialty*
Prior to providing documents for record review, the undersigned complied with the provisions of Labor Code section 4062.3. The undersigned hereby attests that the number of pages (including cover letters and all other correspondence) provided to the physician are:*
Digital Signature*
File Upload*

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CCR 9793 (n) “Record Review” means the review by a physician of documents sent to the physician in connection with a medical-legal evaluation or request for report. The documents may consist of medical records, legal transcripts, medical test results, and or other relevant documents. For purposes of record review, a page is defined as an 8 ½ by 11 single-sided document, chart or paper, whether in physical or electronic form. Multiple condensed pages or documents displayed on a single page shall be charged as separate pages. Any documents sent to the physician for record review must be accompanied by a declaration under penalty of perjury that the provider of the documents has complied with the provisions of Labor Code section 4062.3 before providing the documents to the physician. The declaration must also contain an attestation as to the total page count of the documents provided. A physician may not bill for review of documents that are not provided with this accompanying required declaration from the document provider. Any documents or records that are sent to the physician without the required declaration and attestation shall not be considered available to the physician or received by the physician for purposes of any regulatory or statutory duty of the physician regarding records and report writing.
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