Expert services may be requested by any of the following:

    1. Submit online request using the following form

    2. Complete this form, print and fax it to (909) 946-0347

    3. Simply call toll free at 888-MCS-4321

     

    * = Required information

NOTE: By registering and logging in, expert requests are streamlined as our system will recall your basic contact information.

 

You may log into the site here
 


* SERVICES REQUESTED: (Check all that apply)

Independent Medical Examination

Record/Peer Review Only           

Diagnostic Study Re-interpretation

Utilization / Bill Review

Medical Malpractice Review

Worker’s Compensation Evaluation – QME/AME/IME

Disability Evaluation           

Accident Reconstruction / Biomechanical Analysis

Technical Review:  Type:  

Other:

                                                             CLIENT INFORMATION
* Firm/Company Name:
* First Name:
* Last Name:
Representation Information:
If "Other" please specify
Contact Person (if different from above):
* Street Address:
* City:
* State:
* Zip code:
* Telephone:
Ext:
Fax:
Email Address:

Mailing Address (if different from street address):

City:
State:
Zip:

                                                              BILLING INFORMATION

Billing information is same as contact information. If not, please complete:
Firm/Company Name:
Attention:
Address:
City:
State:
Zip code:
Telephone:
Ext:
Fax:
Email Address:

                                                                  CASE INFORMATION
Case Name:
File#:
Claim#:
D.O.L.:
Insured:
Case Venue (include city, division and state):
Please select one ---->:
Trial/Arbitration Date:
Time Constraints or Deadlines:
* Patient Name:
Case/Injury Details:
Treating Physician(s):
Opposing Expert(s):
Special Instructions:

                                                                 EXPERT INFORMATION
Type of expert needed:
Sub-Specialty area:
Please contact me to discuss experts. Qualified staff members can assist you with expert recommendations.
ADDITIONAL COMMENTS/FEEDBACK:

 

- If you prefer not to submit this information online, click here to print this form,

then fax it to us at (909) 946-0347.

 

- If you wish to submit your information online, but also want a copy for your file, click here to print this form first, then click button below.

PLEASE MAIL ALL RECORDS AND CORRESPONDENCE FOR EXPERTS TO OUR ADMINISTRATION OFFICE:

Medical Consultant Services, Inc.,

2377 W. Foothill Blvd., Suite 9, Upland, CA 91786

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