MedicoLegal Consultants Medical Reviewer Information

Reviewer’s Information Form
   MedicoLegal Consultants
    11041 Santa Monica Boulevard #719
    Los Angeles, CA 90025

    Please print out and complete form and send to us with your CV and registration fee ($25)

Please print or type below. Leave blank items that do not apply.

Name and Professional Degrees
Title
Institution or Company
Preferred Contact	Home Office
Street Address
City, State, Zip
Office Telephone
Office Fax
Home Telephone
Mobile Telephone
E-mail
Specialty 1
Specialty 2
Other Expertise
Social Security or Tax ID No.
States Licensed
Fees	MD or PhD $150 per hour; RN, DDS, DO, DC, MS etc. $75-$100 There is a three hour limit unless prior authorization given.
Any adverse reports in the National Practitioners Data Bank?	No Yes If yes, please explain on the back of this page.
Experience as medical reviewer?	No Yes If yes, please note approximate number and general nature of cases on the back of this page.
Retired? How Long?	No Yes
Do you do independent medical examinations (IME)?	No Yes If yes, list fees:
Willing to testify in court?	No Yes
Willing to do medical malpractice cases?	No Defense Only Plaintiff and Defense
Additional Comments	Use back of this page

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