Schema SupplementalLienFormAndSection4903.05cDeclaration.xsd


attribute form default:  unqualified
element form default:  qualified
targetNamespace:  http://www.dir.ca.gov/dwc/EAMS/JET/Schemas/Forms/ProviderDeclaration
 
Elements  Complex types  Simple types 
ProviderDeclaration  HeaderSection  AcceptFilingOfFalseDeclarationWarningAndContinue 
InjuredWorker  ADJNumber 
LienClaimant  DeclarationStatementCode 
Provider  LienReservationNumber 
ProviderDeclaration  SignatureOfLienClaimant 
ProviderDeclarationForLienForm 


attribute form default:  unqualified
element form default:  qualified
targetNamespace:  http://www.dir.ca.gov/dwc/EAMS/PresentTermSolution/Schemas/Common/CommonFields
 
Simple types 
caseNumber 
checkBox 
ptsDate 
typeCode1 
typeCode3 
versionNumber 


element ProviderDeclaration
diagram SupplementalLienFormAndSection4903.05cDeclaration_p1.png
namespace http://www.dir.ca.gov/dwc/EAMS/JET/Schemas/Forms/ProviderDeclaration
type ProviderDeclaration
properties
content complex
children HeaderSection InjuredWorker LienClaimant Provider DeclarationStatementCode DateOfSignature SignatureOfLienClaimant AcceptFilingOfFalseDeclarationWarningAndContinue
source <xs:element name="ProviderDeclaration" type="ProviderDeclaration"/>

complexType HeaderSection
diagram SupplementalLienFormAndSection4903.05cDeclaration_p2.png
namespace http://www.dir.ca.gov/dwc/EAMS/JET/Schemas/Forms/ProviderDeclaration
children VersionNumber
used by
element ProviderDeclaration/HeaderSection
source <xs:complexType name="HeaderSection">
 
<xs:sequence>
   
<xs:element name="VersionNumber" type="CF:versionNumber" fixed="1.0"/>
 
</xs:sequence>
</xs:complexType>

element HeaderSection/VersionNumber
diagram SupplementalLienFormAndSection4903.05cDeclaration_p3.png
namespace http://www.dir.ca.gov/dwc/EAMS/JET/Schemas/Forms/ProviderDeclaration
type versionNumber
properties
isRef 0
content simple
fixed 1.0
source <xs:element name="VersionNumber" type="CF:versionNumber" fixed="1.0"/>

complexType InjuredWorker
diagram SupplementalLienFormAndSection4903.05cDeclaration_p4.png
namespace http://www.dir.ca.gov/dwc/EAMS/JET/Schemas/Forms/ProviderDeclaration
children FirstName MiddleInitial LastName ClaimsAdministrator ADJNumber LienReservationNumber
used by
element ProviderDeclaration/InjuredWorker
annotation
documentation
Represents data about the injured worker
source <xs:complexType name="InjuredWorker">
 
<xs:annotation>
   
<xs:documentation>Represents data about the injured worker</xs:documentation>
 
</xs:annotation>
 
<xs:all>
   
<xs:element name="FirstName">
     
<xs:simpleType>
       
<xs:restriction base="xs:string">
         
<xs:minLength value="1"/>
         
<xs:maxLength value="25"/>
         
<xs:whiteSpace value="preserve"/>
       
</xs:restriction>
     
</xs:simpleType>
   
</xs:element>
   
<xs:element name="MiddleInitial" minOccurs="0">
     
<xs:simpleType>
       
<xs:restriction base="xs:string">
         
<xs:minLength value="1"/>
         
<xs:maxLength value="10"/>
         
<xs:whiteSpace value="preserve"/>
       
</xs:restriction>
     
</xs:simpleType>
   
</xs:element>
   
<xs:element name="LastName">
     
<xs:simpleType>
       
<xs:restriction base="xs:string">
         
<xs:minLength value="1"/>
         
<xs:maxLength value="25"/>
         
<xs:whiteSpace value="preserve"/>
       
</xs:restriction>
     
</xs:simpleType>
   
</xs:element>
   
<xs:element name="ClaimsAdministrator">
     
<xs:simpleType>
       
<xs:restriction base="xs:string">
         
<xs:minLength value="1"/>
         
<xs:maxLength value="55"/>
         
<xs:whiteSpace value="preserve"/>
       
</xs:restriction>
     
</xs:simpleType>
   
</xs:element>
   
<xs:element name="ADJNumber" type="ADJNumber"/>
   
<xs:element name="LienReservationNumber" type="LienReservationNumber"/>
 
</xs:all>
</xs:complexType>

element InjuredWorker/FirstName
diagram SupplementalLienFormAndSection4903.05cDeclaration_p5.png
namespace http://www.dir.ca.gov/dwc/EAMS/JET/Schemas/Forms/ProviderDeclaration
type restriction of xs:string
properties
isRef 0
content simple
facets
Kind Value annotation 
minLength 
maxLength 25 
whiteSpace preserve 
source <xs:element name="FirstName">
 
<xs:simpleType>
   
<xs:restriction base="xs:string">
     
<xs:minLength value="1"/>
     
<xs:maxLength value="25"/>
     
<xs:whiteSpace value="preserve"/>
   
</xs:restriction>
 
</xs:simpleType>
</xs:element>

element InjuredWorker/MiddleInitial
diagram SupplementalLienFormAndSection4903.05cDeclaration_p6.png
namespace http://www.dir.ca.gov/dwc/EAMS/JET/Schemas/Forms/ProviderDeclaration
type restriction of xs:string
properties
isRef 0
minOcc 0
maxOcc 1
content simple
facets
Kind Value annotation 
minLength 
maxLength 10 
whiteSpace preserve 
source <xs:element name="MiddleInitial" minOccurs="0">
 
<xs:simpleType>
   
<xs:restriction base="xs:string">
     
<xs:minLength value="1"/>
     
<xs:maxLength value="10"/>
     
<xs:whiteSpace value="preserve"/>
   
</xs:restriction>
 
</xs:simpleType>
</xs:element>

element InjuredWorker/LastName
diagram SupplementalLienFormAndSection4903.05cDeclaration_p7.png
namespace http://www.dir.ca.gov/dwc/EAMS/JET/Schemas/Forms/ProviderDeclaration
type restriction of xs:string
properties
isRef 0
content simple
facets
Kind Value annotation 
minLength 
maxLength 25 
whiteSpace preserve 
source <xs:element name="LastName">
 
<xs:simpleType>
   
<xs:restriction base="xs:string">
     
<xs:minLength value="1"/>
     
<xs:maxLength value="25"/>
     
<xs:whiteSpace value="preserve"/>
   
</xs:restriction>
 
</xs:simpleType>
</xs:element>

element InjuredWorker/ClaimsAdministrator
diagram SupplementalLienFormAndSection4903.05cDeclaration_p8.png
namespace http://www.dir.ca.gov/dwc/EAMS/JET/Schemas/Forms/ProviderDeclaration
type restriction of xs:string
properties
isRef 0
content simple
facets
Kind Value annotation 
minLength 
maxLength 55 
whiteSpace preserve 
source <xs:element name="ClaimsAdministrator">
 
<xs:simpleType>
   
<xs:restriction base="xs:string">
     
<xs:minLength value="1"/>
     
<xs:maxLength value="55"/>
     
<xs:whiteSpace value="preserve"/>
   
</xs:restriction>
 
</xs:simpleType>
</xs:element>

element InjuredWorker/ADJNumber
diagram SupplementalLienFormAndSection4903.05cDeclaration_p9.png
namespace http://www.dir.ca.gov/dwc/EAMS/JET/Schemas/Forms/ProviderDeclaration
type ADJNumber
properties
isRef 0
content simple
facets
Kind Value annotation 
minLength 
maxLength 12 
pattern [A-Z][A-Z][A-Z]([0-9])* 
source <xs:element name="ADJNumber" type="ADJNumber"/>

element InjuredWorker/LienReservationNumber
diagram SupplementalLienFormAndSection4903.05cDeclaration_p10.png
namespace http://www.dir.ca.gov/dwc/EAMS/JET/Schemas/Forms/ProviderDeclaration
type LienReservationNumber
properties
isRef 0
content simple
facets
Kind Value annotation 
minLength 
maxLength 20 
source <xs:element name="LienReservationNumber" type="LienReservationNumber"/>

complexType LienClaimant
diagram SupplementalLienFormAndSection4903.05cDeclaration_p11.png
namespace http://www.dir.ca.gov/dwc/EAMS/JET/Schemas/Forms/ProviderDeclaration
children LienClaimantEntityType OrganizationName FirstName MiddleInitial LastName
used by
element ProviderDeclaration/LienClaimant
source <xs:complexType name="LienClaimant">
 
<xs:all>
   
<xs:element name="LienClaimantEntityType">
     
<xs:simpleType>
       
<xs:annotation>
         
<xs:documentation>Specifies whether the lien claimant making this declaration is an
                            Individual or an Organization. Valid values are:
                            "O" - for organization
                            "I" - for individual
                       
</xs:documentation>
       
</xs:annotation>
       
<xs:restriction base="xs:string">
         
<xs:enumeration value="O"/>
         
<xs:enumeration value="I"/>
       
</xs:restriction>
     
</xs:simpleType>
   
</xs:element>
   
<xs:element name="OrganizationName" minOccurs="0">
     
<xs:simpleType>
       
<xs:restriction base="xs:string">
         
<xs:minLength value="1"/>
         
<xs:maxLength value="49"/>
       
</xs:restriction>
     
</xs:simpleType>
   
</xs:element>
   
<xs:element name="FirstName" minOccurs="0">
     
<xs:simpleType>
       
<xs:restriction base="xs:string">
         
<xs:minLength value="1"/>
         
<xs:maxLength value="25"/>
         
<xs:whiteSpace value="preserve"/>
       
</xs:restriction>
     
</xs:simpleType>
   
</xs:element>
   
<xs:element name="MiddleInitial" minOccurs="0">
     
<xs:simpleType>
       
<xs:restriction base="xs:string">
         
<xs:minLength value="1"/>
         
<xs:maxLength value="10"/>
         
<xs:whiteSpace value="preserve"/>
       
</xs:restriction>
     
</xs:simpleType>
   
</xs:element>
   
<xs:element name="LastName" minOccurs="0">
     
<xs:simpleType>
       
<xs:restriction base="xs:string">
         
<xs:minLength value="1"/>
         
<xs:maxLength value="25"/>
         
<xs:whiteSpace value="preserve"/>
       
</xs:restriction>
     
</xs:simpleType>
   
</xs:element>
 
</xs:all>
</xs:complexType>

element LienClaimant/LienClaimantEntityType
diagram SupplementalLienFormAndSection4903.05cDeclaration_p12.png
namespace http://www.dir.ca.gov/dwc/EAMS/JET/Schemas/Forms/ProviderDeclaration
type restriction of xs:string
properties
isRef 0
content simple
facets
Kind Value annotation 
enumeration 
enumeration 
source <xs:element name="LienClaimantEntityType">
 
<xs:simpleType>
   
<xs:annotation>
     
<xs:documentation>Specifies whether the lien claimant making this declaration is an
                            Individual or an Organization. Valid values are:
                            "O" - for organization
                            "I" - for individual
                       
</xs:documentation>
   
</xs:annotation>
   
<xs:restriction base="xs:string">
     
<xs:enumeration value="O"/>
     
<xs:enumeration value="I"/>
   
</xs:restriction>
 
</xs:simpleType>
</xs:element>

element LienClaimant/OrganizationName
diagram SupplementalLienFormAndSection4903.05cDeclaration_p13.png
namespace http://www.dir.ca.gov/dwc/EAMS/JET/Schemas/Forms/ProviderDeclaration
type restriction of xs:string
properties
isRef 0
minOcc 0
maxOcc 1
content simple
facets
Kind Value annotation 
minLength 
maxLength 49 
source <xs:element name="OrganizationName" minOccurs="0">
 
<xs:simpleType>
   
<xs:restriction base="xs:string">
     
<xs:minLength value="1"/>
     
<xs:maxLength value="49"/>
   
</xs:restriction>
 
</xs:simpleType>
</xs:element>

element LienClaimant/FirstName
diagram SupplementalLienFormAndSection4903.05cDeclaration_p14.png
namespace http://www.dir.ca.gov/dwc/EAMS/JET/Schemas/Forms/ProviderDeclaration
type restriction of xs:string
properties
isRef 0
minOcc 0
maxOcc 1
content simple
facets
Kind Value annotation 
minLength 
maxLength 25 
whiteSpace preserve 
source <xs:element name="FirstName" minOccurs="0">
 
<xs:simpleType>
   
<xs:restriction base="xs:string">
     
<xs:minLength value="1"/>
     
<xs:maxLength value="25"/>
     
<xs:whiteSpace value="preserve"/>
   
</xs:restriction>
 
</xs:simpleType>
</xs:element>

element LienClaimant/MiddleInitial
diagram SupplementalLienFormAndSection4903.05cDeclaration_p15.png
namespace http://www.dir.ca.gov/dwc/EAMS/JET/Schemas/Forms/ProviderDeclaration
type restriction of xs:string
properties
isRef 0
minOcc 0
maxOcc 1
content simple
facets
Kind Value annotation 
minLength 
maxLength 10 
whiteSpace preserve 
source <xs:element name="MiddleInitial" minOccurs="0">
 
<xs:simpleType>
   
<xs:restriction base="xs:string">
     
<xs:minLength value="1"/>
     
<xs:maxLength value="10"/>
     
<xs:whiteSpace value="preserve"/>
   
</xs:restriction>
 
</xs:simpleType>
</xs:element>

element LienClaimant/LastName
diagram SupplementalLienFormAndSection4903.05cDeclaration_p16.png
namespace http://www.dir.ca.gov/dwc/EAMS/JET/Schemas/Forms/ProviderDeclaration
type restriction of xs:string
properties
isRef 0
minOcc 0
maxOcc 1
content simple
facets
Kind Value annotation 
minLength 
maxLength 25 
whiteSpace preserve 
source <xs:element name="LastName" minOccurs="0">
 
<xs:simpleType>
   
<xs:restriction base="xs:string">
     
<xs:minLength value="1"/>
     
<xs:maxLength value="25"/>
     
<xs:whiteSpace value="preserve"/>
   
</xs:restriction>
 
</xs:simpleType>
</xs:element>

complexType Provider
diagram SupplementalLienFormAndSection4903.05cDeclaration_p17.png
namespace http://www.dir.ca.gov/dwc/EAMS/JET/Schemas/Forms/ProviderDeclaration
children ProviderType OtherProviderType RenderingProviderName RenderingProviderNPI RenderingProviderLicenseOrCertificationNumber BillingProviderName BillingProviderNPI InitialDateOfService
used by
elements ProviderDeclaration/Provider ProviderDeclarationForLienForm/Provider
source <xs:complexType name="Provider">
 
<xs:all>
   
<xs:element name="ProviderType">
     
<xs:annotation>
       
<xs:documentation>See {link} for the list of valid provider types.
                   
</xs:documentation>
     
</xs:annotation>
     
<xs:simpleType>
       
<xs:restriction base="xs:string">
         
<xs:minLength value="1"/>
         
<xs:maxLength value="10"/>
       
</xs:restriction>
     
</xs:simpleType>
   
</xs:element>
   
<xs:element name="OtherProviderType" minOccurs="0">
     
<xs:simpleType>
       
<xs:restriction base="xs:string">
         
<xs:minLength value="1"/>
         
<xs:maxLength value="40"/>
       
</xs:restriction>
     
</xs:simpleType>
   
</xs:element>
   
<xs:element name="RenderingProviderName">
     
<xs:simpleType>
       
<xs:restriction base="xs:string">
         
<xs:minLength value="1"/>
         
<xs:maxLength value="50"/>
       
</xs:restriction>
     
</xs:simpleType>
   
</xs:element>
   
<xs:element name="RenderingProviderNPI" minOccurs="0">
     
<xs:simpleType>
       
<xs:restriction base="xs:string">
         
<xs:minLength value="10"/>
         
<xs:maxLength value="10"/>
         
<xs:pattern value="\d\d\d\d\d\d\d\d\d\d"/>
       
</xs:restriction>
     
</xs:simpleType>
   
</xs:element>
   
<xs:element name="RenderingProviderLicenseOrCertificationNumber" minOccurs="0">
     
<xs:simpleType>
       
<xs:restriction base="xs:string">
         
<xs:minLength value="1"/>
         
<xs:maxLength value="10"/>
       
</xs:restriction>
     
</xs:simpleType>
   
</xs:element>
   
<xs:element name="BillingProviderName">
     
<xs:simpleType>
       
<xs:restriction base="xs:string">
         
<xs:minLength value="1"/>
         
<xs:maxLength value="50"/>
       
</xs:restriction>
     
</xs:simpleType>
   
</xs:element>
   
<xs:element name="BillingProviderNPI" minOccurs="0">
     
<xs:simpleType>
       
<xs:restriction base="xs:string">
         
<xs:minLength value="10"/>
         
<xs:maxLength value="10"/>
         
<xs:pattern value="\d\d\d\d\d\d\d\d\d\d"/>
       
</xs:restriction>
     
</xs:simpleType>
   
</xs:element>
   
<xs:element name="InitialDateOfService" type="CF:ptsDate"/>
 
</xs:all>
</xs:complexType>

element Provider/ProviderType
diagram SupplementalLienFormAndSection4903.05cDeclaration_p18.png
namespace http://www.dir.ca.gov/dwc/EAMS/JET/Schemas/Forms/ProviderDeclaration
type restriction of xs:string
properties
isRef 0
content simple
facets
Kind Value annotation 
minLength 
maxLength 10 
annotation
documentation
See {link} for the list of valid provider types.
                   
source <xs:element name="ProviderType">
 
<xs:annotation>
   
<xs:documentation>See {link} for the list of valid provider types.
                   
</xs:documentation>
 
</xs:annotation>
 
<xs:simpleType>
   
<xs:restriction base="xs:string">
     
<xs:minLength value="1"/>
     
<xs:maxLength value="10"/>
   
</xs:restriction>
 
</xs:simpleType>
</xs:element>

element Provider/OtherProviderType
diagram SupplementalLienFormAndSection4903.05cDeclaration_p19.png
namespace http://www.dir.ca.gov/dwc/EAMS/JET/Schemas/Forms/ProviderDeclaration
type restriction of xs:string
properties
isRef 0
minOcc 0
maxOcc 1
content simple
facets
Kind Value annotation 
minLength 
maxLength 40 
source <xs:element name="OtherProviderType" minOccurs="0">
 
<xs:simpleType>
   
<xs:restriction base="xs:string">
     
<xs:minLength value="1"/>
     
<xs:maxLength value="40"/>
   
</xs:restriction>
 
</xs:simpleType>
</xs:element>

element Provider/RenderingProviderName
diagram SupplementalLienFormAndSection4903.05cDeclaration_p20.png
namespace http://www.dir.ca.gov/dwc/EAMS/JET/Schemas/Forms/ProviderDeclaration
type restriction of xs:string
properties
isRef 0
content simple
facets
Kind Value annotation 
minLength 
maxLength 50 
source <xs:element name="RenderingProviderName">
 
<xs:simpleType>
   
<xs:restriction base="xs:string">
     
<xs:minLength value="1"/>
     
<xs:maxLength value="50"/>
   
</xs:restriction>
 
</xs:simpleType>
</xs:element>

element Provider/RenderingProviderNPI
diagram SupplementalLienFormAndSection4903.05cDeclaration_p21.png
namespace http://www.dir.ca.gov/dwc/EAMS/JET/Schemas/Forms/ProviderDeclaration
type restriction of xs:string
properties
isRef 0
minOcc 0
maxOcc 1
content simple
facets
Kind Value annotation 
minLength 10 
maxLength 10 
pattern \d\d\d\d\d\d\d\d\d\d 
source <xs:element name="RenderingProviderNPI" minOccurs="0">
 
<xs:simpleType>
   
<xs:restriction base="xs:string">
     
<xs:minLength value="10"/>
     
<xs:maxLength value="10"/>
     
<xs:pattern value="\d\d\d\d\d\d\d\d\d\d"/>
   
</xs:restriction>
 
</xs:simpleType>
</xs:element>

element Provider/RenderingProviderLicenseOrCertificationNumber
diagram SupplementalLienFormAndSection4903.05cDeclaration_p22.png
namespace http://www.dir.ca.gov/dwc/EAMS/JET/Schemas/Forms/ProviderDeclaration
type restriction of xs:string
properties
isRef 0
minOcc 0
maxOcc 1
content simple
facets
Kind Value annotation 
minLength 
maxLength 10 
source <xs:element name="RenderingProviderLicenseOrCertificationNumber" minOccurs="0">
 
<xs:simpleType>
   
<xs:restriction base="xs:string">
     
<xs:minLength value="1"/>
     
<xs:maxLength value="10"/>
   
</xs:restriction>
 
</xs:simpleType>
</xs:element>

element Provider/BillingProviderName
diagram SupplementalLienFormAndSection4903.05cDeclaration_p23.png
namespace http://www.dir.ca.gov/dwc/EAMS/JET/Schemas/Forms/ProviderDeclaration
type restriction of xs:string
properties
isRef 0
content simple
facets
Kind Value annotation 
minLength 
maxLength 50 
source <xs:element name="BillingProviderName">
 
<xs:simpleType>
   
<xs:restriction base="xs:string">
     
<xs:minLength value="1"/>
     
<xs:maxLength value="50"/>
   
</xs:restriction>
 
</xs:simpleType>
</xs:element>

element Provider/BillingProviderNPI
diagram SupplementalLienFormAndSection4903.05cDeclaration_p24.png
namespace http://www.dir.ca.gov/dwc/EAMS/JET/Schemas/Forms/ProviderDeclaration
type restriction of xs:string
properties
isRef 0
minOcc 0
maxOcc 1
content simple
facets
Kind Value annotation 
minLength 10 
maxLength 10 
pattern \d\d\d\d\d\d\d\d\d\d 
source <xs:element name="BillingProviderNPI" minOccurs="0">
 
<xs:simpleType>
   
<xs:restriction base="xs:string">
     
<xs:minLength value="10"/>
     
<xs:maxLength value="10"/>
     
<xs:pattern value="\d\d\d\d\d\d\d\d\d\d"/>
   
</xs:restriction>
 
</xs:simpleType>
</xs:element>

element Provider/InitialDateOfService
diagram SupplementalLienFormAndSection4903.05cDeclaration_p25.png
namespace http://www.dir.ca.gov/dwc/EAMS/JET/Schemas/Forms/ProviderDeclaration
type ptsDate
properties
isRef 0
content simple
facets
Kind Value annotation 
pattern [0-1][0-9]/[0-3][0-9]/[1-2][0-9][0-9][0-9] 
source <xs:element name="InitialDateOfService" type="CF:ptsDate"/>

complexType ProviderDeclaration
diagram SupplementalLienFormAndSection4903.05cDeclaration_p26.png
namespace http://www.dir.ca.gov/dwc/EAMS/JET/Schemas/Forms/ProviderDeclaration
children HeaderSection InjuredWorker LienClaimant Provider DeclarationStatementCode DateOfSignature SignatureOfLienClaimant AcceptFilingOfFalseDeclarationWarningAndContinue
used by
element ProviderDeclaration
annotation
documentation
This type represents a standalone Provider Declaration Form
source <xs:complexType name="ProviderDeclaration">
 
<xs:annotation>
   
<xs:documentation>This type represents a standalone Provider Declaration Form</xs:documentation>
 
</xs:annotation>
 
<xs:sequence>
   
<xs:element name="HeaderSection" type="HeaderSection"/>
   
<xs:element name="InjuredWorker" type="InjuredWorker"/>
   
<xs:element name="LienClaimant" type="LienClaimant"/>
   
<xs:element name="Provider" type="Provider" minOccurs="1" maxOccurs="3"/>
   
<xs:element name="DeclarationStatementCode" type="DeclarationStatementCode"/>
   
<xs:element name="DateOfSignature" type="CF:ptsDate"/>
   
<xs:element name="SignatureOfLienClaimant" type="SignatureOfLienClaimant"/>
   
<xs:element name="AcceptFilingOfFalseDeclarationWarningAndContinue" type="AcceptFilingOfFalseDeclarationWarningAndContinue"/>
 
</xs:sequence>
</xs:complexType>

element ProviderDeclaration/HeaderSection
diagram SupplementalLienFormAndSection4903.05cDeclaration_p27.png
namespace http://www.dir.ca.gov/dwc/EAMS/JET/Schemas/Forms/ProviderDeclaration
type HeaderSection
properties
isRef 0
content complex
children VersionNumber
source <xs:element name="HeaderSection" type="HeaderSection"/>

element ProviderDeclaration/InjuredWorker
diagram SupplementalLienFormAndSection4903.05cDeclaration_p28.png
namespace http://www.dir.ca.gov/dwc/EAMS/JET/Schemas/Forms/ProviderDeclaration
type InjuredWorker
properties
isRef 0
content complex
children FirstName MiddleInitial LastName ClaimsAdministrator ADJNumber LienReservationNumber
source <xs:element name="InjuredWorker" type="InjuredWorker"/>

element ProviderDeclaration/LienClaimant
diagram SupplementalLienFormAndSection4903.05cDeclaration_p29.png
namespace http://www.dir.ca.gov/dwc/EAMS/JET/Schemas/Forms/ProviderDeclaration
type LienClaimant
properties
isRef 0
content complex
children LienClaimantEntityType OrganizationName FirstName MiddleInitial LastName
source <xs:element name="LienClaimant" type="LienClaimant"/>

element ProviderDeclaration/Provider
diagram SupplementalLienFormAndSection4903.05cDeclaration_p30.png
namespace http://www.dir.ca.gov/dwc/EAMS/JET/Schemas/Forms/ProviderDeclaration
type Provider
properties
isRef 0
minOcc 1
maxOcc 3
content complex
children ProviderType OtherProviderType RenderingProviderName RenderingProviderNPI RenderingProviderLicenseOrCertificationNumber BillingProviderName BillingProviderNPI InitialDateOfService
source <xs:element name="Provider" type="Provider" minOccurs="1" maxOccurs="3"/>

element ProviderDeclaration/DeclarationStatementCode
diagram SupplementalLienFormAndSection4903.05cDeclaration_p31.png
namespace http://www.dir.ca.gov/dwc/EAMS/JET/Schemas/Forms/ProviderDeclaration
type DeclarationStatementCode
properties
isRef 0
content simple
facets
Kind Value annotation 
enumeration TXMPN 
enumeration AMEQME 
enumeration TX4610 
enumeration NOMPN 
enumeration NOMEDTX 
enumeration EMERGMED 
enumeration OTHERML 
source <xs:element name="DeclarationStatementCode" type="DeclarationStatementCode"/>

element ProviderDeclaration/DateOfSignature
diagram SupplementalLienFormAndSection4903.05cDeclaration_p32.png
namespace http://www.dir.ca.gov/dwc/EAMS/JET/Schemas/Forms/ProviderDeclaration
type ptsDate
properties
isRef 0
content simple
facets
Kind Value annotation 
pattern [0-1][0-9]/[0-3][0-9]/[1-2][0-9][0-9][0-9] 
source <xs:element name="DateOfSignature" type="CF:ptsDate"/>

element ProviderDeclaration/SignatureOfLienClaimant
diagram SupplementalLienFormAndSection4903.05cDeclaration_p33.png
namespace http://www.dir.ca.gov/dwc/EAMS/JET/Schemas/Forms/ProviderDeclaration
type SignatureOfLienClaimant
properties
isRef 0
content simple
facets
Kind Value annotation 
minLength 
maxLength 49 
source <xs:element name="SignatureOfLienClaimant" type="SignatureOfLienClaimant"/>

element ProviderDeclaration/AcceptFilingOfFalseDeclarationWarningAndContinue
diagram SupplementalLienFormAndSection4903.05cDeclaration_p34.png
namespace http://www.dir.ca.gov/dwc/EAMS/JET/Schemas/Forms/ProviderDeclaration
type AcceptFilingOfFalseDeclarationWarningAndContinue
properties
isRef 0
content simple
facets
Kind Value annotation 
whiteSpace collapse 
source <xs:element name="AcceptFilingOfFalseDeclarationWarningAndContinue" type="AcceptFilingOfFalseDeclarationWarningAndContinue"/>

complexType ProviderDeclarationForLienForm
diagram SupplementalLienFormAndSection4903.05cDeclaration_p35.png
namespace http://www.dir.ca.gov/dwc/EAMS/JET/Schemas/Forms/ProviderDeclaration
children Provider DeclarationStatementCode SignatureOfLienClaimant DateOfSignature AcceptFilingOfFalseDeclarationWarningAndContinue
annotation
documentation
This type represents the Provider Declaration section of the Lien Form
source <xs:complexType name="ProviderDeclarationForLienForm">
 
<xs:annotation>
   
<xs:documentation>This type represents the Provider Declaration section of the Lien Form</xs:documentation>
 
</xs:annotation>
 
<xs:sequence>
   
<xs:element name="Provider" type="Provider" minOccurs="1" maxOccurs="3"/>
   
<xs:element name="DeclarationStatementCode" type="DeclarationStatementCode">
     
<xs:annotation>
       
<xs:documentation>Declaration pursuant to Labor Code section 4903.05(c). (Completion of this
                        section is required if filing a lien under Labor Code section 4903(b).)
</xs:documentation>
     
</xs:annotation>
   
</xs:element>
   
<xs:element name="SignatureOfLienClaimant" type="SignatureOfLienClaimant"/>
   
<xs:element name="DateOfSignature" type="CF:ptsDate"/>
   
<xs:element name="AcceptFilingOfFalseDeclarationWarningAndContinue" type="AcceptFilingOfFalseDeclarationWarningAndContinue"/>
 
</xs:sequence>
</xs:complexType>

element ProviderDeclarationForLienForm/Provider
diagram SupplementalLienFormAndSection4903.05cDeclaration_p36.png
namespace http://www.dir.ca.gov/dwc/EAMS/JET/Schemas/Forms/ProviderDeclaration
type Provider
properties
isRef 0
minOcc 1
maxOcc 3
content complex
children ProviderType OtherProviderType RenderingProviderName RenderingProviderNPI RenderingProviderLicenseOrCertificationNumber BillingProviderName BillingProviderNPI InitialDateOfService
source <xs:element name="Provider" type="Provider" minOccurs="1" maxOccurs="3"/>

element ProviderDeclarationForLienForm/DeclarationStatementCode
diagram SupplementalLienFormAndSection4903.05cDeclaration_p37.png
namespace http://www.dir.ca.gov/dwc/EAMS/JET/Schemas/Forms/ProviderDeclaration
type DeclarationStatementCode
properties
isRef 0
content simple
facets
Kind Value annotation 
enumeration TXMPN 
enumeration AMEQME 
enumeration TX4610 
enumeration NOMPN 
enumeration NOMEDTX 
enumeration EMERGMED 
enumeration OTHERML 
annotation
documentation
Declaration pursuant to Labor Code section 4903.05(c). (Completion of this
                        section is required if filing a lien under Labor Code section 4903(b).)
source <xs:element name="DeclarationStatementCode" type="DeclarationStatementCode">
 
<xs:annotation>
   
<xs:documentation>Declaration pursuant to Labor Code section 4903.05(c). (Completion of this
                        section is required if filing a lien under Labor Code section 4903(b).)
</xs:documentation>
 
</xs:annotation>
</xs:element>

element ProviderDeclarationForLienForm/SignatureOfLienClaimant
diagram SupplementalLienFormAndSection4903.05cDeclaration_p38.png
namespace http://www.dir.ca.gov/dwc/EAMS/JET/Schemas/Forms/ProviderDeclaration
type SignatureOfLienClaimant
properties
isRef 0
content simple
facets
Kind Value annotation 
minLength 
maxLength 49 
source <xs:element name="SignatureOfLienClaimant" type="SignatureOfLienClaimant"/>

element ProviderDeclarationForLienForm/DateOfSignature
diagram SupplementalLienFormAndSection4903.05cDeclaration_p39.png
namespace http://www.dir.ca.gov/dwc/EAMS/JET/Schemas/Forms/ProviderDeclaration
type ptsDate
properties
isRef 0
content simple
facets
Kind Value annotation 
pattern [0-1][0-9]/[0-3][0-9]/[1-2][0-9][0-9][0-9] 
source <xs:element name="DateOfSignature" type="CF:ptsDate"/>

element ProviderDeclarationForLienForm/AcceptFilingOfFalseDeclarationWarningAndContinue
diagram SupplementalLienFormAndSection4903.05cDeclaration_p40.png
namespace http://www.dir.ca.gov/dwc/EAMS/JET/Schemas/Forms/ProviderDeclaration
type AcceptFilingOfFalseDeclarationWarningAndContinue
properties
isRef 0
content simple
facets
Kind Value annotation 
whiteSpace collapse 
source <xs:element name="AcceptFilingOfFalseDeclarationWarningAndContinue" type="AcceptFilingOfFalseDeclarationWarningAndContinue"/>

simpleType AcceptFilingOfFalseDeclarationWarningAndContinue
namespace http://www.dir.ca.gov/dwc/EAMS/JET/Schemas/Forms/ProviderDeclaration
type checkBox
properties
base CF:checkBox
used by
elements ProviderDeclaration/AcceptFilingOfFalseDeclarationWarningAndContinue ProviderDeclarationForLienForm/AcceptFilingOfFalseDeclarationWarningAndContinue
facets
Kind Value annotation 
whiteSpace collapse 
annotation
documentation
Warning:
                Pursuant to Labor Code Section 4903.05(c), the filing of a false declaration
                shall be grounds for dismissal of your lien.  Do you want to continue?
           
source <xs:simpleType name="AcceptFilingOfFalseDeclarationWarningAndContinue">
 
<xs:annotation>
   
<xs:documentation>Warning:
                Pursuant to Labor Code Section 4903.05(c), the filing of a false declaration
                shall be grounds for dismissal of your lien.  Do you want to continue?
           
</xs:documentation>
 
</xs:annotation>
 
<xs:restriction base="CF:checkBox"/>
</xs:simpleType>

simpleType ADJNumber
namespace http://www.dir.ca.gov/dwc/EAMS/JET/Schemas/Forms/ProviderDeclaration
type restriction of xs:string
properties
base xs:string
used by
element InjuredWorker/ADJNumber
facets
Kind Value annotation 
minLength 
maxLength 12 
pattern [A-Z][A-Z][A-Z]([0-9])* 
source <xs:simpleType name="ADJNumber">
 
<xs:restriction base="xs:string">
   
<xs:minLength value="4"/>
   
<xs:maxLength value="12"/>
   
<xs:pattern value="[A-Z][A-Z][A-Z]([0-9])*"/>
 
</xs:restriction>
</xs:simpleType>

simpleType DeclarationStatementCode
namespace http://www.dir.ca.gov/dwc/EAMS/JET/Schemas/Forms/ProviderDeclaration
type restriction of xs:string
properties
base xs:string
used by
elements ProviderDeclaration/DeclarationStatementCode ProviderDeclarationForLienForm/DeclarationStatementCode
facets
Kind Value annotation 
enumeration TXMPN 
enumeration AMEQME 
enumeration TX4610 
enumeration NOMPN 
enumeration NOMEDTX 
enumeration EMERGMED 
enumeration OTHERML 
annotation
documentation

                This field is used to indicate that the lien claimant is making the following declaration:

                "I declare under penalty of perjury under the laws of the State of California that the Lien Claimant
                is a provider or proper assignee of the provider and the following is true and correct:

                • The dispute that is the subject of this lien is not subject to independent medical review
                and independent bill review: and

                • The provider:"

                Select the code corresponding to ONE of the following statements:

                Valid Values:

                "TXMPN"    - "is the employee's treating physician providing care through a
                              medical provider network."

                "AMEQME"   - "is the agreed medical evaluator or qualified medical evaluator."

                "TX4610"   - "has provided treatment authorized by the employer or claims administrator
                              under Labor Code Section 4610."

                "NOMPN"    - "has made a diligent search and determined that the employer does not have
                              a medical provider network in place."

                "NOMEDTX"  - "has documentation that medical treatment has been neglected or
                              unreasonably refused to the employee as provided in Labor Code Section 4600."

                "EMERGMED" - "can show that the expense was incurred for an emergency medical
                              condition, as defined in Health and Safety Code Section 1317.1(b)."

                "OTHERML"  - "is a certified interpreter rendering services during a medical-legal
                              examination, a copy service providing medical-legal services or has an expense
                              allowed as a lien under rules adopted by the administrative director."
           
source <xs:simpleType name="DeclarationStatementCode">
 
<xs:annotation>
   
<xs:documentation>
                This field is used to indicate that the lien claimant is making the following declaration:

                "I declare under penalty of perjury under the laws of the State of California that the Lien Claimant
                is a provider or proper assignee of the provider and the following is true and correct:

                • The dispute that is the subject of this lien is not subject to independent medical review
                and independent bill review: and

                • The provider:"

                Select the code corresponding to ONE of the following statements:

                Valid Values:

                "TXMPN"    - "is the employee's treating physician providing care through a
                              medical provider network."

                "AMEQME"   - "is the agreed medical evaluator or qualified medical evaluator."

                "TX4610"   - "has provided treatment authorized by the employer or claims administrator
                              under Labor Code Section 4610."

                "NOMPN"    - "has made a diligent search and determined that the employer does not have
                              a medical provider network in place."

                "NOMEDTX"  - "has documentation that medical treatment has been neglected or
                              unreasonably refused to the employee as provided in Labor Code Section 4600."

                "EMERGMED" - "can show that the expense was incurred for an emergency medical
                              condition, as defined in Health and Safety Code Section 1317.1(b)."

                "OTHERML"  - "is a certified interpreter rendering services during a medical-legal
                              examination, a copy service providing medical-legal services or has an expense
                              allowed as a lien under rules adopted by the administrative director."
           
</xs:documentation>
 
</xs:annotation>
 
<xs:restriction base="xs:string">
   
<xs:enumeration value="TXMPN"/>
   
<xs:enumeration value="AMEQME"/>
   
<xs:enumeration value="TX4610"/>
   
<xs:enumeration value="NOMPN"/>
   
<xs:enumeration value="NOMEDTX"/>
   
<xs:enumeration value="EMERGMED"/>
   
<xs:enumeration value="OTHERML"/>
 
</xs:restriction>
</xs:simpleType>

simpleType LienReservationNumber
namespace http://www.dir.ca.gov/dwc/EAMS/JET/Schemas/Forms/ProviderDeclaration
type restriction of xs:string
properties
base xs:string
used by
element InjuredWorker/LienReservationNumber
facets
Kind Value annotation 
minLength 
maxLength 20 
source <xs:simpleType name="LienReservationNumber">
 
<xs:restriction base="xs:string">
   
<xs:minLength value="1"/>
   
<xs:maxLength value="20"/>
 
</xs:restriction>
</xs:simpleType>

simpleType SignatureOfLienClaimant
namespace http://www.dir.ca.gov/dwc/EAMS/JET/Schemas/Forms/ProviderDeclaration
type restriction of xs:string
properties
base xs:string
used by
elements ProviderDeclaration/SignatureOfLienClaimant ProviderDeclarationForLienForm/SignatureOfLienClaimant
facets
Kind Value annotation 
minLength 
maxLength 49 
annotation
documentation
An S signature is required. An S signature consists of the letter "S" followed by
                the name of the person signing the document, in the following format:
                S JOHN JONES. Do not enter a middle name or initial.
           
source <xs:simpleType name="SignatureOfLienClaimant">
 
<xs:annotation>
   
<xs:documentation>An S signature is required. An S signature consists of the letter "S" followed by
                the name of the person signing the document, in the following format:
                S JOHN JONES. Do not enter a middle name or initial.
           
</xs:documentation>
 
</xs:annotation>
 
<xs:restriction base="xs:string">
   
<xs:minLength value="3"/>
   
<xs:maxLength value="49"/>
 
</xs:restriction>
</xs:simpleType>

simpleType caseNumber
namespace http://www.dir.ca.gov/dwc/EAMS/PresentTermSolution/Schemas/Common/CommonFields
type restriction of xs:string
properties
base xs:string
facets
Kind Value annotation 
minLength 
maxLength 20 
pattern [A-Z][A-Z][A-Z]([0-9])* 
source <xs:simpleType name="caseNumber">
 
<xs:restriction base="xs:string">
   
<xs:maxLength value="20"/>
   
<xs:minLength value="4"/>
   
<xs:pattern value="[A-Z][A-Z][A-Z]([0-9])*"/>
 
</xs:restriction>
</xs:simpleType>

simpleType checkBox
namespace http://www.dir.ca.gov/dwc/EAMS/PresentTermSolution/Schemas/Common/CommonFields
type restriction of xs:boolean
properties
base xs:boolean
used by
simpleType AcceptFilingOfFalseDeclarationWarningAndContinue
facets
Kind Value annotation 
whiteSpace collapse 
source <xs:simpleType name="checkBox">
 
<xs:restriction base="xs:boolean">
   
<xs:whiteSpace value="collapse"/>
 
</xs:restriction>
</xs:simpleType>

simpleType ptsDate
namespace http://www.dir.ca.gov/dwc/EAMS/PresentTermSolution/Schemas/Common/CommonFields
type restriction of xs:string
properties
base xs:string
used by
elements ProviderDeclaration/DateOfSignature ProviderDeclarationForLienForm/DateOfSignature Provider/InitialDateOfService
facets
Kind Value annotation 
pattern [0-1][0-9]/[0-3][0-9]/[1-2][0-9][0-9][0-9] 
source <xs:simpleType name="ptsDate">
 
<xs:restriction base="xs:string">
   
<xs:pattern value="[0-1][0-9]/[0-3][0-9]/[1-2][0-9][0-9][0-9]"/>
 
</xs:restriction>
</xs:simpleType>

simpleType typeCode1
namespace http://www.dir.ca.gov/dwc/EAMS/PresentTermSolution/Schemas/Common/CommonFields
type restriction of xs:string
properties
base xs:string
facets
Kind Value annotation 
length 
whiteSpace collapse 
source <xs:simpleType name="typeCode1">
 
<xs:restriction base="xs:string">
   
<xs:length value="1" fixed="true"/>
   
<xs:whiteSpace value="collapse"/>
 
</xs:restriction>
</xs:simpleType>

simpleType typeCode3
namespace http://www.dir.ca.gov/dwc/EAMS/PresentTermSolution/Schemas/Common/CommonFields
type restriction of xs:string
properties
base xs:string
facets
Kind Value annotation 
length 
whiteSpace collapse 
source <xs:simpleType name="typeCode3">
 
<xs:restriction base="xs:string">
   
<xs:length value="3" fixed="true"/>
   
<xs:whiteSpace value="collapse"/>
 
</xs:restriction>
</xs:simpleType>

simpleType versionNumber
namespace http://www.dir.ca.gov/dwc/EAMS/PresentTermSolution/Schemas/Common/CommonFields
type xs:float
properties
base xs:float
used by
element HeaderSection/VersionNumber
annotation
documentation
PTS Version Number
source <xs:simpleType name="versionNumber">
 
<xs:annotation>
   
<xs:documentation>PTS Version Number</xs:documentation>
 
</xs:annotation>
 
<xs:restriction base="xs:float"/>
</xs:simpleType>


XML Schema documentation generated by XMLSpy Schema Editor http://www.altova.com/xmlspy