Legal Bill Payments PayPal Form Date: Fax #: Bill To: Contact: Patient Name: Independent Medical Exam arrowup6 Independent Medical Exam Date Select a Service Independent Medical Exam without video ($2,000.00) Independent Medical Exam with video or Attorney Present ($3,000.00) Total Deposition arrowup6 Deposition (1 Hour Minimum Required) Date Select a Service Deposition without video $1,250.00 Deposition *with video $1,750.00 Any time after 1 hour shall be billed in 15 min. increments Quantity Total Deposition - Worker's Comp arrowup6 Deposition Date Select a Service Workers Comp- per hr includes prep time and appearance Quantity Total Telephone Conference arrowup6 Telephone Conference Date Select a Service Telephone Conference Billed in 15 minute increments Quantity Enter total minutes Total In Person Conference With Attorney arrowup6 In Person Conference With Attorney Date Select a Service In Person Conference with Attorney 30 minute minimum Total In Person Conference With Adjuster / Case Manager arrowup6 In Person Conference With Adjuster / Case Manager Date Select a Service In Person Conference with Adjuster / Case Manager Billed in 15 minute increments Quantity Enter total minutes Total Reports: Including opinions based upon examination and/or treatment arrowup6 Reports: Including opinions based upon examination and/or treatment Date Select a Service Reports including opinions based upon examination and/or treatment Total Peer /Case Review arrowup6 Peer /Case Review Date Select a Service Peer Case Review Billed in 15 min increments Quantity Enter total minutes Total Trial Fee arrowup6 Trial Fee Date Select a Service Half Day Full Day Total Form Completion arrowup6 Form Completion Date Select a Service Form Completion Quantity Enter total minutes Total Review of Films X-Rays/MRI and/or Chart arrowup6 Review of Films X-Rays/MRI and/or Chart Date Select a Service4 Review of Films X-Rays/MRI and/or Chart 30 minute minimum Quantity Enter total minutes Total Records/Billing Requests arrowup6 Records/Billing Requests $1.00 for the first 25 pages and .25 for every page afterwards Date Select a Service Record/Billing Request Quantity Enter the total number of pages Total The total is automatically calculated Legal-Bill Total The total is automatically calculated Pay With Credit Card If you are human, leave this field blank.