CodeWise Solutions LLC

CodeWise Solutions LLC

Retention Request
Instructions

Please complete the following form. This information will allow us to determine if our expert is a good fit for your case as well as complete conflict checks prior to retention.
Name of Person Completing this Form

NameTitle
Retaining Counsel Information
Case Information

Please indicate which client you represent by placing an asterisk (*) before or after the part name.

"Subject Incident of Case" refers to the causal incident for the case. Auto, slip/fall, dog bite, etc...
Specific Case Information (Needed for Conflict Check)
What type of report are you requesting?
What reimbursement methodology is being requested? (you may select all that apply)
Additional Information:
If Commercial insurance is requested, please specify the insurance. If UCR is requested, please include the specific percentile requested.
Please describe any State, Locality, or specific regulations we should be aware of, as they relate to your case.
For example, Florida Statute 768.0427.
Thank you for completing your request!

Please fill out the below information before signing off. You can print to a PDF and return via email, or you may simply press "Submit" to send us your request.
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Email
example@example.com
Signature
Should be Empty:

Instructions