Request For Consultative Rating {DWC-AD 104 (DEU)}

State of California Division of Workers' Compensation Disability Evaluation Unit REQUEST FOR CONSULTATIVE RATING Indicate type of request: Mail-in Walk-in DEU Use Only 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 party INSTRUCTIONS FOR WALK-IN'S: 1. Attach this request form to copies of the medical reports that you wish 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. Date of Birth SSN (Numbers Only) Date of Injury 1 Case Number 1 Date of Injury 2 Case Number 2 Date of Injury 3 Case Number 3 Date of Injury 4 Case Number 4 Date of Injury 5 Case Number 5 MM/DD/YYYY MM/DD/YYYY MM/DD/YYYY MM/DD/YYYY MM/DD/YYYY MM/DD/YYYY Injured worker First Name MI Last Name Suffix(Jr,Sr,etc) Occupation (attach description if unclear) DWC-AD form104 (DEU) (Rev. 11/2008) (Page 1) RCR Insurance Claim Number Date of report(s) to be rated and doctor's name: MM/DD/YYYY MM/DD/YYYY MM/DD/YYYY This case has been set on for: MM/DD/YYYY for the type of hearing checked below: Rating MSC Trial Conference Rating requested by: Name of firm Representing the Employee Employer A copy of this request has been served on Firm Name Firm Address 1/PO Box (Please leave blank spaces between numbers, names or words) Firm Address 2/PO Box (Please leave blank spaces between numbers, names or words) City State Zip Code DWC-AD form104 (DEU) (Rev. 11/2008) (Page 2) RCR