Supplemental Lien Form and Section 4903.05(c) Declaration
First Name
MI
Last Name
Claims Administrator
ADJ Number
LR
N
Organization
Individual
Organization Name
First Name
Last Name
Provider Type
Other Provider Type
Rendering Provider's Name
Rendering Provider's NPI
Rendering Provider's License/Cert No
Billing Provider's Name
Billing Provider's NPI
Initial Date of Service
Provider Type
Other Provider Type
Rendering Provider's Name
Rendering Provider's NPI
Rendering Provider's License/Cert No
Billing Provider's Name
Billing Provider's NPI
Initial Date of Service
Provider Type
Other Provider Type
Rendering Provider's Name
Rendering Provider's NPI
Rendering Provider's License/Cert No
Billing Provider's Name
Billing Provider's NPI
Initial Date of Service
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).)
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 (must select only one option from dropdown).
• (A) is the employee's treating physician providing care through a medical provider
•
network.
• (B) is the agreed medical evaluator or qualified medical evaluator.
(C) has provided treatment authorized by the employer or claims administrator
•
under Labor Code Section 4610.
(D) has made a diligent search and determined that the employer does not have a
•
medical provider network in place.
(E) has documentation that medical treatment has been neglected or unreasonably
•
refused to the employee as provided in Labor Code Section 4600.
(F) can show that the expense was incurred for an emergency medical condition,
•
as (defined in Health and Safety Code Section 1317.1(b).
(G) 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.
Lien Claimant Signature