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Medical File(s) Request
The entire contents of all files in your possession or under
your control, for all dates of
injuries or illness or for any purpose, whether industrial or non-industrial,
including but not
limited to all:
• Files,
• Charts,
• Reports (which have not been previously served upon the requesting party)
• Notes, writings, and diagrams,
• Forms,
• Printouts,
• Test results,
• Lab results,
• All correspondence and telephone conversation notes (including printouts of
all Email
and computer notes) regarding this injured person to and from all sources,
including but
not limited to other medical facilities and doctors, and to and from any
representative of any
insurance company, employer, investigator and attorneys.
Employer’s Claim File Request
1) All documents contained in the employer’s Personnel file, Claim file, or
Workers’
Compensation file for the named Applicant.
2) A printout of all electronic mail between the Claims Adjuster and the
Employer
3) Applicant’s application for employment or contract for services and all
employment
documents regarding services performed by Applicant for or on behalf of
employer.
4) All written evaluations and documents of employment, title, service
position, duties,
disciplines, reprimands and changes of title, duties or rate of compensation.
5) All investigation reports, correspondence or memoranda regarding any claims
alleged by Applicant.
6) All documentation, writings, and memoranda (including Email and computer
notes)
pertaining to any injuries or claims made by the Applicant.
7) All correspondence, memoranda, forms and notices transmitted to or received
from Applicant.
8) Copy of all correspondence (including printouts of Electronic Mail) sent to
or received
from any physicians regarding any claim or injury alleged by the Applicant.
9) Copy of all written or recorded statements made by the Applicant.
10) Copy of telephone log, and all written and computer notes and/or Email of
any
conversation, if any, by any employer’s representative with the Applicant, any
physician or
physician’s office personnel, or insurance company representative regarding the
Applicant.
11) Any and all medical or dispensary records.
Employee Policy and/or Handbook Request
Any and all employer’s written company policies in your possession or under
your control
effecting employees, including handbook, manual, procedures, memorandum or
email that
were in effect or were distributed or made available to employees during the
period of time
that the above named person was employed at your company.
Personnel Files AND Payroll Records Request
This notice of deposition includes a demand for all documents under your
custody and
control regarding the above claim number as described below for the applicant,
herein
claimant, listed on the notice of deposition.
There are TWO types of records being requested, Personnel and Payroll.
1) Personnel:
12) All documents contained in the employer’s Personnel file, Claim file, or
Workers’
Compensation file for the named Applicant.
13) A printout of all electronic mail between the Claims Adjuster and the
Employer
14) Applicant’s application for employment or contract for services and all
employment
documents regarding services performed by Applicant for or on behalf of
employer.
15) All written evaluations and documents of employment, title, service
position, duties,
disciplines, reprimands and changes of title, duties or rate of compensation.
16) All investigation reports, correspondence or memoranda regarding any claims
alleged
by Applicant.
17) All documentation, writings, and memoranda (including Email and computer
notes)
pertaining to any injuries or claims made by the Applicant.
18) All correspondence, memoranda, forms and notices transmitted to or received
from Applicant.
19) Copy of all correspondence (including printouts of Electronic Mail) sent to
or received
from any physicians regarding any claim or injury alleged by the Applicant.
20) Copy of all written or recorded statements made by the Applicant.
21) Copy of telephone log, and all written and computer notes and/or Email of
any
conversation, if any, by any employer’s representative with the Applicant, any
physician or
physician’s office personnel, or insurance company representative regarding the
Applicant.
22) Any and all medical or dispensary records.
2) Payroll:
Date range: If a date range is listed above under “Records to produce” only
provide records
during that range. Otherwise, provide records for a period of one year prior to
the last date
the employee performed any work for the deponent (you):
1) A printout, listing, or report for each pay period showing the following:
• Wages paid, including gross amount, each deduction, and net payment
• Hours, including regular, overtime, sick, holiday and vacation
• Any other benefit paid, if any
If necessary, multiple printouts (listing or reports) may be produced to
satisfy this request.
Each printout, listing or report shall include the date of the pay period, and
the date of payment.
1) In addition to the above, a copy of the employee’s W-2 or 1099 form for a
period of one
year prior to the last date the employee listed on this Notice performed any
work for the
deponent (you).
A W-2 form is not sufficient to comply with this request without the above
described printout, listing, or report(s).
This demand does NOT include:
1) Any documentation or correspondence between an attorney representing the
deponent
and any employee of the deponent.
2) Any documentation or correspondence between the designated spokesperson
representing the employer and an attorney who represents that employer unless
that
documentation has been disclosed to a third party or an insurance company.
3) Any documents prepared by any attorney that are the attorney's impressions
conclusions, opinions or legal research or theories.
4) That portion of a report prepared by an investigator at the request of an
attorney that
contains the investigator's impressions, conclusions, opinions or theories.
5) Any surveillance video of claimant where the claimant's deposition has not
been taken
and the deponent intends to take the deposition of the claimant and that
surveillance video
has not been disclose to a third party or physician.
Radiographic Film Request
Any and all radiographic film in your possession pertaining to the patient
listed above.
Employer’s Safety Program, Repetitive Motion Injuries Program, and
Injury Prevention Program Request
Any and all documents in your possession or under your control constituting the
employer’s
safety program, the employer’s Repetitive Motion Injuries program, and the
Injury Prevention
Program that were in effect or printed during the time that the above named
person was
employed with your company. The Repetitive Motion Injuries program is defined
under
California Labor Code Section 6357 and Title 8 California Code of Regulations
section 5110.
The Injury Prevention Program is defined under California Labor Code section
6401.7 and
Title 8 California Code of Regulations section 3203.
Psychiatric Records Request (use with Release – see How
To Obtain
Psychiatric Records)
The entire contents of all Psychiatric/Mental Health files in your possession
or under your
control, for all dates of injuries or illness or for any purpose, whether
industrial or
non-industrial, including but not limited to all:
• Files,
• Charts,
• Reports (which have not been previously served upon the requesting party)
• Notes, writings, and diagrams,
• Forms,
• Printouts,
• Test results,
• Lab results,
• All correspondence and telephone conversation notes to and from all sources,
including
but not limited to other medical facilities and doctors, and to and from any
representative of
any insurance company, employer, investigator and attorneys.
Material Safety Data Sheets (MSDS) Request
• Any and all Material Safety Data Sheets (MSDS) in your possession or under
your control
pertaining to toxins and chemicals that the Applicant named on this Deposition
Notice/SDT
was, or may have been exposed to while employed with the employer/defendant
listed
on this Deposition Notice/SDT.
• Please note any date ranges and/or exclusions listed above.
Medical Provider Network Notification Request
• A copy of all Employee Notification documents required per Regulation 9767.12
(Medical Provider Network notification).
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