Electronic Service of Medical-Legal Report
(For requests for the medical legal report to be submitted electronically)
Name of Person Submitting Form
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First Name
Last Name
Date of Submission
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-
Month
-
Day
Year
Date
Email
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example@example.com
Phone Number
*
Please enter a valid phone number.
Company
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Relationship To Applicant
*
Please Select
Applicant
Applicant Attorney
Defense Attorney
Claims Adjuster
Applicant Name
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First Name
Last Name
Claim Number
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Name of QME/AME
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Please Select
Larry Ozowara, MD
Specialty
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Please Select
Psychiatry
Service Type
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Please Select
Evaluation or Re-evaluation
Supplemental Report
Date of Evaluation
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-
Month
-
Day
Year
Date
Title 8 CCR §36.7
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 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.
Digital Signature
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Submit
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