MC-350(A-13b(5)) CASE NAME: CASE NUMBER: MEDICAL SERVICE PROVIDER ATTACHMENT TO PETITION TO APPROVE COMPROMISE OF CLAIM OR ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT (A person using Judicial Council form MC-350 to petition for court approval of the compromise of a claim of a minor or an action involving a minor or person with a disability, or disposition of the proceeds of a judgment in favor of a minor or person with a disability, must provide information about medical service providers that (1) have liens for payment of charges for medical care and treatment provided to the minor or disabled claimant or (2) were paid (or will be paid from the proceeds) by petitioner for which petitioner requests reimbursement from the proceeds of the compromise or judgment. (See item 13b(5) on page 5 of form MC-350.) One or more copies of this form may be used as Attachment 13b(5) to that form to provide the required information about additional medical service providers not listed in that form.) Attachment 13b(5) to form MC-350 13 b. (5) (b) The name of each medical service provider that furnished care and treatment to claimant and (1) has a lien for all or any part of the charges or (2) was paid (or will be paid from the proceeds) by petitioner for which petitioner requests reimbursement; the amounts charged and paid; the amount of negotiated reduction of charges, if any; and the amount to be paid from the proceeds of the settlement or judgment to each provider are as follows: (A) Provider (name): (B) Address: (C) (D) (E) (F) Amount charged: $ Amount paid (whether or not by insurance): $( Negotiated reduction, if any: $( Amount to be paid from proceeds of settlement or judgment: $ ) ) (A) Provider (name): (B) Address: (C) (D) (E) (F) Amount charged: $ Amount paid (whether or not by insurance): $( Negotiated reduction, if any: $( Amount to be paid from proceeds of settlement or judgment: $ ) ) (A) Provider (name): (B) Address: (C) (D) (E) (F) Amount charged: $ Amount paid (whether or not by insurance): $( Negotiated reduction, if any: $( Amount to be paid from proceeds of settlement or judgment: $ ) ) (A) Provider (name): (B) Address: (C) (D) (E) (F) Amount charged: $ Amount paid (whether or not by insurance): $( Negotiated reduction, if any: $( Amount to be paid from proceeds of settlement or judgment: $ Page Form Approved for Optional Use Judicial Council of California MC-350(A-13b(5)) [New January 1, 2010] of ) ) attached pages MEDICAL SERVICE PROVIDER ATTACHMENT TO PETITION TO APPROVE COMPROMISE OF CLAIM OR ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT (Miscellaneous) Code of Civil Procedure, § 372 et seq.; Probate Code, § 3500 et seq.; Cal. Rules of Court, rules 3.1384, 7.950, 7.951 www.courtinfo.ca.gov American LegalNet, Inc. www.FormsWorkFlow.com