Expert services may be requested by any of the following:

    1. Submit the secure online request form below. All information sent to MCS will be encrypted for security and privacy purposes.

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

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

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 * = Required information

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* SERVICE REQUESTED:

GENERAL INFORMATION

Independent Medical Examination

Record/Peer Review Only           

Diagnostic Study Re-interpretation

Utilization / Bill Review

Accident Reconstruction / Biomechanical Analysis

Technical Analysis:  Type:  

Written Report?:
Verbal Report?:
Rush Due Date:
Court Case Number:
Case Venue (include city, division and state):
Trial Date:
Arbitration Date:

REFERRAL INFORMATION
* Firm/Company Name:
* Street Address:
* City:
* State:
* Zip code:
* First Name:
* Last Name:
* Telephone:
Ext:
Direct Telephone:
Email Address:
Paralegal:
Paralegal Email:
Paralegal Phone:
Legal Secretary:
Legal Secretary Email:
Legal Secretary Phone:

 BILLING INFORMATION

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

PATIENT INFORMATION
* Patient Name:
* Date of Birth:
* Date of Loss:
* Residence City:
* Residence State:

* Interpreter?:

* Language:
* Treating Physician(s):
* Nature of Injury:
* Type of Accident:
Special Instructions:

EXPERT INFORMATION
* Expert Name or Specialty:  MCS to Recommend Expert?:
Additional Expert Name or Specialty:  MCS to Recommend Expert?:
Additional Expert Name or Specialty:  MCS to Recommend Expert?:

 

- 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.


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

experts@mcsxperts.com

Medical Consultant Services, Inc.,

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