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Michael S. Blott,D.C.

1 18586 Via Loma Dr.

Poway CA 92064
858-487-6940
Facsimile:
206-222-2691

2 Telephone:
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WORKERS’ COMPENSATION APPEALS BOARD

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STATE OF CALIFORNIA
_______________________________________

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FIRST LAST,
Applicant,

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CASE NO. ADJ

v.

PETITION FOR DETERMINATION OF
NON-IBR MEDICAL-LEGAL DISPUTE
FILED BY A
MEDICAL-LEGAL PROVIDER

EMPLOYER;
10 INS. CO. ADMINISTERED BY,

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Defendants.

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Michael S. Blott, D.C. is the QME that has not been paid for services provided in this case.

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I.

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STATEMENT OF FACTS

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Provider was contacted by ______ on behalf of applicant ____ to provide a QME opinion

20 regarding the industrial injury alleged in case number ADJ_______. Provider reviewed the
21 relevant materials provided to him in preparation for an evaluation of the Applicant. On Month
22 99, 20XX Provider evaluated the Applicant, The resulting report is dated __/__/__ and is attached
23 hereto as Exhibit “A.”
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A bill was sent to Defendant on __/__/__ with proof of service by mail and is attached

25 hereto as Exhibit “B.”
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No payment or Explanation of Review has been received by Provider.
II.

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PETITION FOR DETERMINATION OF NON-IBR
MEDICAL-LEGAL DISPUTE FILED BY A MEDICALLEGAL PROVIDER

Title 8 § 1045. 6 B. 27 28 -2- PETITION FOR DETERMINATION OF NON-IBR MEDICAL-LEGAL DISPUTE FILED BY A MEDICALLEGAL PROVIDER . Defendant has waived all objections. This issue is Ripe for Adjudication.1(g). Award X Thousand dollars ($X. D.C.C. The fee charged for these steps are the standard fees in 5 the Medlegal fee schedule used by Qualified Medical Examiners. 2014 BY: _________________________________________ Michael S.1 Michael S. Blott. is entitled to an Award 16 for payment of X Thousand dollars ($X. Code 12 Regs. 21 2. 7 As defendant has not responded to the bill sent more than sixty days ago.000.1(f)(1) 9 (A)(i). Should a hearing become necessary. Fees are reasonably. The evidentiary record supporting the order consists of the 10 exhibits submitted with this Verified Petition. Grant its Petition.000. Code Regs. the Petition is 8 ripe for adjudication. 3 The items listed on Exhibit “B” represent the necessary steps to producing proper 4 Qualified Medical Evaluation Report. No hearing is necessary. Petitioner 11 hereby reserves its rights to seek attorney’s fees and costs as well as sanctions under Cal. Title 8 § 1045. (apply late payment penalties as 23 provided in LC4622) 24 25 26 DATED: Month 99. Title 8 § 1045. 22 3. Take further action as necessary and appropriate. Cal.00). 18 PRAYER 19 WHEREFORE petitioner prays that the Court: 20 1.1 DISCUSSION 2 A. Code Regs. 17 IV.00) for QME services provided in this case. actually. D. 13 III. 14 CONCLUSION 15 Pursuant to Cal. and necessarily incurred. Blott.

C.C. and on that ground allege that the matters stated there are true and correct. I am familiar with the matters stated in the foregoing and make this verification on behalf of Michael S. That I am authorized to made and do make this declaration on behalf of Michael S. D. pursuant to California Code of Civil Procedure section 446. has professional offices at 17586 Via Loma Dr Poway. I declare under penalty of perjury that the above is true and correct according to the laws of the State of California and that the same was signed by me on the 99th day of Month. Blott. 14 15 16 Provider 17 18 19 20 21 22 23 24 25 26 27 28 -3- PETITION FOR DETERMINATION OF NON-IBR MEDICAL-LEGAL DISPUTE FILED BY A MEDICALLEGAL PROVIDER .. D.1 2 VERIFICATION 3 4 5 6 7 8 9 10 11 12 13 That Michael S. That I have read the foregoing PETITION FOR DETERMINATION OF NON-IBR MEDICAL LEGAL DISPUTE FILED BY A MEDICAL-LEGAL PROVIDER and am informed and believe the matters therein to be true and correct. 2014. CA 92064. Blott.C. Blott. D.