This type represents a standalone Provider Declaration Form
This type represents the Provider Declaration section of the Lien Form
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).)
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?
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.
Represents data about the injured worker
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."
Specifies whether the lien claimant making this declaration is an
Individual or an Organization. Valid values are:
"O" - for organization
"I" - for individual
See {link} for the list of valid provider types.