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Medical Index and Copy Service Request
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Medical Index and Copy Service Request
Request Date:
Analyst Name:
Number of Copy Sets:
Analyst Email:
Please check one:
Paper File
PDF via Email (EFlo documents)
Non-Litigated Case
(Medical Index should include mandatory language to injured worker regarding PQME)
Due Date:
Analyst Phone:
Information will appear on medical index as it is specified below:
Name of Injured:
Claim Number:
WCAB Number:
Date of Injury:
Non-Medical Records to Appear on Medical Index:
(Please check documents to be included)
Application for Adjudication
(Date)
DWC-1
(Date)
Job Analysis
(Date)
Other
(Date)
Other
(Date)
Other
(Date)
Delivery of Medical Records:
(For delivery of medical records please specify address for delivery)
1. Name of Facility/Provider:
Address:
Phone:
2. Name of Facility/Provider:
Address:
Phone:
Comments:
If you do not receive a confirmation email within 24 hrs. please contact us at 951.779.1630.
