Social Security Number:
Date of Injury:
The undersigned declares under penalty of perjury that the following lien(s) or claim(s) for payment are subject to the Notice of Withdrawal Of Lien executed on March 31, 1995 in conjunction with the Stipulation ForEntry Of Judgement filed in The People of the State of California vs. Mark Kaplan, M.D. et al., Superior Court Case No. BC 085378 by Mark Kaplan, M.D., individually, and Polina Ioffe, individually, and on behalf of "CRESCENT HEIGHTS MEDICAL GROUP; MARK KAPLAN, M.D., a California Medical Corporation and dba HARPER MEDICAL GROUP, HARPER MEDICAL ASSOCIATES, VERWOOD MEDICAL GROUP, VALNOR MEDICAL GROUP, PARK DEFENCE EXPERTS MEDICAL ASSOCIATES; COMP MED CO; HARPER MEDICAL CLINIC, a California Medical Corporation; HARPER CLINCS, INC., a California corporation; HARPER MEDICAL GROUP, INC. A Medical Corporation; PARK MEDICAL GROUP, a Partnership owned by Mark Kaplan, M.D., Corporation and Harper Medical Associates, Inc.; SIG COMPREHENSIVE SERVICES, A California Corporation; ASSOCIATED DIAGNOSTIC AND IMAGING, a Sole Proprietor; BENTEN MEDICAL ASSOCIATES, a Partnership owned by Mark Kaplan, M.D. Corporation and Harper Medical Associates, Inc.; WILTON BUSINESS ASSOCIATES, A California Corporation;"
|Amount of Lien or Claim||Entity|
The undersigned agrees that the filing of this document shall constitute resolution of the above liens and/or claims for payment made by the above entities in accord with the above mentioned Notice Of Withdrawal Of Lien and Stipulation For Entry Of Final Judgement without further order of the Workers' Compensation Appeals Board.
Signature of Attorney or Representative |
for Employer or Carrier
A copy of the petition was served by mail or delivered to the following: