Submitting this form will send a request to our med-legal scheduling department.  Once received, we will process your request and send notifications to all parties.  If you have any questions regarding med-legal scheduling or this form, please feel free to contact us by phone at 415-409-7364 or by e-mail at
This form is for carrier and attorney use only. * = Required Information.  Use n/a if not applicable.


For your convenience, you can attach a document to this submission (such as an intake sheet, a panel list, etc.).

Patient Information

Workers' Compensation Information

Applicant's Attorney

Defense Attorney

Requesting Party

Appointment Information

Please note that only listed physicians and offices can be selected.  If a physician is not listed, they are not available for any type med-legal evaluation.  If a location is not listed, it is not available for med-legals even if an initial evaluation took place at that location.  
- Availability updated 8/11/2015