Free DWC AD form 104 DEU - California

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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 Case Number 5 Date of Injury 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)

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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: Rating MSC Trial Conference Rating requested by:

MM/DD/YYYY

for the type of hearing checked below:

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)

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