STATE OF CALIFORNIA BILLING AND STATEMENT OF CHARGES FOR MEDICAL-LEGAL REPORTS Department of Industrial Relations Division of Workers' Compensation (DWC) INDUSTRIAL MEDICAL COUNCIL (IMC) This form must accompany all initial comprehensive medical-legal reports filed in a proceeding before the State of California Workers' Compensation Appeals Board (WCAB). For information and instructions for completing this form see reverse side. Report Requested by: Applicant Defendant To (Requester): Applicant and Defendant IMC - Medical Unit (Attention) WCAB No. (Address) (City/State/Zip) Physician/Practitioner Name IRS No. Physician/Practitioner Address (Street and Number) City Patient Name Phone No. State & Zip Date of Injury Patient Address (Number and Street) City State & Zip Employer Name Claim No. (if available) Employer Address (Number and Street) City State & Zip Certification: I certify that I have performed all aspects of this medical-legal consultation within the scope of my professional discipline, that the report complies with Title 8, Section 10606, entitled "Physician's Reports as Evidence"* (see reverse), and that this billing and statement of charges accurately reflect all services rendered. Signature of Certifying Physician/Practitioner Type Name of Certifying Physician/Practitioner Physician/Practitioner License No. Name of Person Assisting Certifying Physician/Practitioner (Typed) Physician/Practitioner License No. Name of Person Assisting Certifying Physician/Practitioner (Typed) Role Physician/Practitioner License No. Role 1. Type of Report (check one): a) Initial Comprehensive d) b) QME Initial Comprehensive AME Initial Comprehensive e) c) IME Initial Comprehensive Other 2. Date of Examination: 3. Date of Billing: 4. Check the specialty under which service was rendered (check only one): Acupuncture (ACA) Cardiology (MMV) Chiropractic (DCH) Dentistry (DDS) Internal Medicine (MMM) Neurology (MPN) Neurosurgery (MMNS) Occupational Medicine (MPO) Ophthalmology (MOP) Optometry (OPT) Orthopedics (MOS) Osteopathic Medicine Physical Medicine and Rehabilitation (MPR) Podiatry (POD) Psychiatry (MPD) Psychology (PSY) Pulmonary Medicine (MMP) Radiology (MRY) Rheumatology (MMR) Other 5. Charge for records review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 6. Charge for medical history and medical examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ . . 7. Charge for report preparation including necessary research . . . . . . . . . . . . . . . . . . . . . . . . $ . 8. Charge for medical-legal report(medical-legal range of fees NOT applicable) (add 5, 6 and 7)Subtotal A $ 9. Additional charge for all other services(medical-legal range of fees NOT applicable) Procedure Code Charge Procedure Code Charge $ $ $ $ $ $ $ $ $ TOTAL CHARGES (add A and B) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Subtotal. B . . . . . . . . . . . . . $ . ..... . . IMC Form 76 (REV. 8/91) IMC-76 2002 © American LegalNet, Inc. Information and Instructions General Information: Labor Code Section 4624. Fees for initial comprehensive industrial medical-legal reports; publishing of fees. (a) From January 1, 1991 until June 30, 1992, and notwithstanding any other section of this article, fees for initial comprehensive industrial medical-legal reports charged by independent medical examiners (IME), agreed medical evaluators (AME), treating physicians and qualified medical evaluators (QME) shall be rebuttably presumed reasonable if the charges do not exceed the fees specified for each specialty category as listed below: Special Category Fee Amount Orthopedics $ 984 Internal Medicine and Cardiology $ 995 Neurology $ 881 Psychiatry $ 1,279 All others $ 866 Charges exceeding the amounts for the involved specialties may be found reasonable if accompanied by supporting information provided by the physician. Instructions for filling out IMC Form 76 by item number: 1. Check appropriate box, indicating type of report for every initial comprehensive medical-legal consultation. Check "other" only if the physician chooses to use this form for a different purpose (such as: re-evaluation, supplemental, narrative, etc.) 2. Enter month/day/year of examination. 3. Enter month/day/year of billing. 4. Check the appropriate box that indicates the specialty of the evaluating physician. If the specialty is not preprinted on the form, check "other" and specify the appropriate specialty. 5. Enter dollar amount charged for records review. 6. Enter dollar amount charged for history and examination. 7. Enter dollar amount charged for report preparation, (including dictating, reviewing outside and/or prior laboratory studies and x-rays, literature review, discussing case with other doctors, etc.) Items No. 5, 6 and 7 must be itemized separately. Do not show a Procedure Code for these charges. 8. Medical-Legal Report Charges (Subtotal A) equals the addition of items 5, 6 and 7 and is used to compile the annual range of medical-legal charges. 9. Additional Charges (Subtotal B) equals the addition of all other services such as lab work, x-rays, diagnostic tests, psychological testing, which are subject to the Official Medical Fee Schedule and should be individually itemized by Procedure Codes. Any other tests or charges not represented by the Official Medical Fee Schedule should be individually itemized. 10. Total charges equals Subtotal A plus Subtotal B (items 8 and 9). Upon completion, return IMC Form 76 (Billing and Statement of Charges) with the medical-legal report to the REQUESTER. DO NOT SEND TO THE WCAB. Requester will file IMC Form 76 and medical-legal report originals with the WCAB. For further information concerning IMC Form 76 or applicable medical-legal range of fees for initial comprehensive medical-legal reports, contact the Industrial Medical Council P. O. Box 603 San Francisco, CA 94101 Phone 1-800-794-6900 * CERTIFICATION: Section 10606, Physician's Report is evidence, "if any person(s) other than the physician signing the report has participated in the examination of the injured employee or in the preparation of the report, the name(s) of such person(s) and their role shall be set forth, including name(s) of person(s) who do the: (1) medical history; (2) physical examination; and (3) drafting, composing and/or editing of the report in whole or in part." (You do not need to show the name of typist, however.) 2002 © American LegalNet, Inc.