To download a form, just click on a link below. You will need Adobe Acrobat Reader to open all files below.
For all WC request, please attach:
1) Application of adjudication 2) Notice of representation 3) HIPPA authorization form
For PI request, please attach:
1) HIPPA authorization form
| Referral Form | Electronic Request Form | Download PDF |
| WCIRB | Download PDF | |
| Affidavit | Download PDF |
| Universal Copy HIPAA Complaint Authorization for the release of patient information | Download PDF |
| Community Hospital of San Bernardino Authorization | Download PDF |
| Department of Health Services County Of Los Angeles | Download PDF |
| Desert Regional Medical Center Authorization | Download PDF |
| Kaiser Permanente- SCPMG Authorization | Download PDF |
| Little Company of Mary - San Pedro Hospital Authorization | Download PDF |
| Loma Linda University Behavioral Medicine Center Authorization | Download PDF |
| Pomona Valley Hospital Medical Center Authorization | Download PDF |
| Presbyterian Intercommunity Hospital Authorization | Download PDF |
| Quest Diagnostics Authorization | Download PDF |
| Rite Aid Attorney Authorization | Download PDF |
| Social Security Administration Consent for Release of Information | Download PDF |
| St. Mary Medical Center Authorization | Download PDF |
| UCI Medical Center Authorization | Download PDF |
| UCLA Healthcare Authorization | Download PDF |
| EDD Authorization For Release Of Information | Download PDF |