Fill and Sign the Dwc Ad Form104 Fill Online Printable Fillable Blank

REQUEST FOR CONSULTATIVE RATINGState of California Division of Workers' Compensation Disability Evaluation Unit DEU Use Only Indicate type of request: INSTRUCTIONS FOR MAIL-IN’S: 1. Attach a photocopy of the medical report(s) for which a rating is \ being requested, if not previously on file. Do not send original reports. 2. Serve a copy of this request on the representative for the opposing p\ arty INSTRUCTIONS FOR WALK-IN’S: 1. Attach this request form to copies of the medical reports that you wi\ sh to have rated. 2. List below the doctor's names and dates of reports to be rated. 3. If a deposition is to be rated, mark or list the pages to be reviewed\ by the rater. Injured worker DWC-AD form104 (DEU) (Rev. 11/2008) (Page 1) MM/DD/YYYY MM/DD/YYYY MM/DD/YYYY MM/DD/YYYY MM/DD/YYYY MM/DD/YYYY RCR Occupation (attach description if unclear) Mail-in Walk-in Case Number 5 Case Number 4 Case Number 3 Case Number 2 Case Number 1 SSN (Numbers Only) Date of Birth Date of Injury 1 Date of Injury 2 Date of Injury 3 Date of Injury 4 Date of Injury 5 Suffix(Jr,Sr,etc) MI Last Name First Name Date of report(s) to be rated and doctor’s name: Rating requested by: Representing the A copy of this request has been served on DWC-AD form104 (DEU) (Rev. 11/2008) (Page 2)MM/DD/YYYY for the type of hearing checked below: RCR Insurance Claim Number MM/DD/YYYY This case has been set on for: Employee Employer Name of firm Firm Address 2/PO Box (Please leave blank spaces between numbers, names\ or words) Firm Address 1/PO Box (Please leave blank spaces between numbers, names\ or words) Zip Code City Firm Name Rating MSC Trial Conference MM/DD/YYYY MM/DD/YYYY State