Pre-Trial Conference Statement Lien Issues Addendum {WCAB 24.1}

STATE OF CALIFORNIA DIVISION OF WORKERS' COMPENSATION WORKERS' COMPENSATION APPEALS BOARD PRE-TRIAL CONFERENCE STATEMENT LIEN ISSUES ADDENDUM (TO BE COMPLETED BY DEFENDANT AND LIEN CLAIMANT-ONE ADDENDUM PAGE FOR EACH LIEN) Case # ADJ LIEN CLAIMANT BALANCE LIEN CLAIMANTS TREATMENT EXPENSE ENTITLEMENT MEDICAL LEGAL EXPENSE ENTITLEMENT INTERPRETING EXPENSE ENTITLEMENT 15% INCREASE/INTEREST (L.C. 4603.2(b)(2)) (treatment) PENALTIES AND INTEREST (L.C. 4622) (med legal) DEFENDANT WHETHER REASONABLY REQUIRED (NECESSITY) Appeal of IMR ____________ Fraud ____________ Conflict of Interest ____________ Mistake of Fact REASONABLENESS/VALUE OF CHARGES Appeal of IBR Determination ____________ Fraud ____________ Conflict of Interest ____________ Mistake of Fact TREATMENT OUTSIDE MPN 24 VISIT CAP NO CONTESTED CLAIM (MED LEGAL) CERTIFICATION AOE/COE BODY PARTS STATUTE OF LIMITATIONS LACHES ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ OTHER (either party)___________________________________________________________________ Lien Claimant________________________________ WCAB Form 24.1 (Revised 2013) American LegalNet, Inc. www.FormsWorkFlow.com Defendant______________________________