Patient Information

    First Name:
    Last Name:
    Date of Birth:
    Social Security Number:
    Email Address:
    Phone:
    Description of the work injury:

    Applicant Attorney

    Firm:
    Attorney:
    Phone Number:
    Email Address:
    Firm Address:
    Comments:
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    Contact

    Phone

    Hemet Office: (951)652-5000
    Menifee Office:(951)672-1866
    Corona Office: (951) 256-1779
    Temecula Office: (951)303-1500
    Riverside Office: (951)924-6500
    San Bernardino Office: (909)567-2917
    Encinitas Office: (951) 303-1500
    La Jolla Office: (951) 303-1500

    Fax Numbers:

    (855)306-0133 - Pharmacy
    (855)306-0134 - Labs, Radiology
    (855)306-0135 - Authorizations