Consult Request Form (Rev. Feb 2002)
REQUEST FOR CONSULTATIVE RATING
State of California
Division of Workers' Compensation
Disability Evaluation Unit
Indicate type of request: ❑ Mail-in
DEU Use Only
INSTRUCTIONS FOR MAIL-IN’S:
1. Enclose pre-addressed envelopes for yourself and the opposing party.
2. Attach a photocopy of the medical report(s) for which a rating is being requested. Do not send original reports.
3. Send this request to the DEU office serving the WCAB location in which the case has been filed.
4. Serve a copy of this request on the representative for the opposing party.
INSTRUCTIONS FOR WALK-IN’S:
1. Place report(s) to be rated on top of the WCAB file, unless report has been placed into evidence.
If report(s) have been placed into evidence, clearly mark them with a paper clip or post-it note.
If a deposition is to be rated, mark or list the pages to be reviewed by the rater.
Injured worker’s name
WCAB case number(s)
Occupation (attach description if unclear)
Date of injury
Date of birth
Social security number
Date of report(s) to be rated and doctor’s name:
This case has been set for:
❑ rating pre-trial
Rating requested by: ___________________________________ representing the
name of firm
A copy of this request has been served on _____________________________________.
name of firm