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Here is the text we could read:

CASE NAME:

CASE NUMBER:

MC-350(A-12b(5))

ADDITIONAL MEDICAL SERVICE PROVIDERS ATTACHMENT 
TO PETITION FOR APPROVAL OF COMPROMISE OF CLAIM OR 
ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT

If you are using form MC-350 to petition for court approval of the compromise of a claim or action or the disposition of the proceeds of a 
judgment for a minor or person with a disability, you must provide complete information, in item 12b(5) of form MC-350, about any 
medical service providers that (1) have liens for payment of charges for medical services provided to the minor or person with a 
disability or (2) you paid (or will pay from the proceeds), for which payment you request reimbursement from the proceeds of the 
compromise or judgment. If you don't have enough room on form MC-350, you may use one or more copies of this form to provide the 
required information about additional medical service providers.

Attachment 12b(5) to form MC-350

12. b.

(5)

(b) Each medical service provider that furnished care and treatment to claimant and (1) has a lien for all or any part of the 

charges or (2) was paid (or will be paid from the proceeds) by petitioner, for which payment petitioner requests 
reimbursement; the amounts charged and paid; the amount of negotiated reductions of charges, if any; and the amount 
to be paid from the proceeds of the settlement or judgment to each provider are as follows: 

(A)   Provider (name): 
(B)   Address:

(C) Amount charged: 
(D) Amount paid (whether or not by insurance): 
(E) Negotiated reduction, if any: 
(F) Amount to be paid from proceeds of settlement or judgment: 

(A)   Provider (name): 
(B)   Address:

(C) Amount charged: 
(D) Amount paid (whether or not by insurance):  
(E) Negotiated reduction, if any: 
(F) Amount to be paid from proceeds of settlement or judgment: 

(A)   Provider (name): 
(B)   Address:

(C) Amount charged: 
(D) Amount paid (whether or not by insurance):
(E) Negotiated reduction, if any: 
(F) Amount to be paid from proceeds of settlement or judgment: 

(A)   Provider (name): 
(B)   Address:

(C) Amount charged: 
(D) Amount paid (whether or not by insurance):
(E) Negotiated reduction, if any: 
(F) Amount to be paid from proceeds of settlement or judgment: 

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Form Approved for Optional Use  
Judicial Council of California 
MC-350(A-12b(5)) [Rev. January 1, 2021]

ADDITIONAL MEDICAL SERVICE PROVIDERS ATTACHMENT 
TO PETITION FOR APPROVAL OF COMPROMISE OF CLAIM OR 
ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT

Code of Civil Procedure, § 372 et seq.; 
Probate Code, §§ 3500, 3600–3613; 
Cal. Rules of Court, rules 3.1384, 7.950 

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Additional Medical Service Providers Attachment to Petition for Approval of Compromise of Claim or Action or Disposition of Proceeds of Judgment

This info page is part of the LIT Lab's Form Explorer project. It is not associated with the California state courts. To learn more about the project, check out our about page.

Downloads: You can download both the original form (last checked 2023-03) and the machine-processed form with normalized data fields.

About This Form:

Sourced from selfhelp.courts.ca.gov (2023-03)
Page(s): 1
Fields(s): 32
Average fields per page: 32
Reading Level: Grade 7
LIST Grouping(s): MO-00-00-00-00.

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Identified Data Fields:

We have done our best to automaticly identify and name form fields according to our naming conventions. When possible, we've used names tied to our question library. See e.g., user1_name. If we think we've found a match to a question in our library, it is highlighted in green. Novel names are auto generated. So, you will probably need to edit some of them if you're trying to stick to the convention.

Here are the fields we could identify.

c_b_page_caption_sf_party_ft was MC-350A-12b5[0].Page1[0].Caption_sf[0].Party_ft[0] (0.52 conf)
c_b_page_sf_case_number was MC-350A-12b5[0].Page1[0].Caption_sf[0].CaseNumber_ft[0] (0.36 conf)
c_b_page_list_l_text_field__1 was MC-350A-12b5[0].Page1[0].List1[0].LI1[0].List1[0].TextField6[0] (0.40 conf)
c_b_page_list_l_fill_text__1 was MC-350A-12b5[0].Page1[0].List1[0].LI1[0].List1[0].LI1[0].FillText84[0] (0.37 conf)
c_b_page_list_l_fill_text__2 was MC-350A-12b5[0].Page1[0].List1[0].LI1[0].List1[0].LI2[0].FillText85[0] (0.37 conf)
c_b_page_list_l_fill_text__3 was MC-350A-12b5[0].Page1[0].List1[0].LI1[0].List1[0].LI3[0].FillText87[0] (0.37 conf)
c_b_page_list_l_fill_text__4 was MC-350A-12b5[0].Page1[0].List1[0].LI1[0].List1[0].LI4[0].FillText88[0] (0.37 conf)
c_b_page_list_l_fill_text__5 was MC-350A-12b5[0].Page1[0].List1[0].LI1[0].List1[0].LI5[0].FillText89[0] (0.37 conf)
c_b_page_list_l_fill_text__6 was MC-350A-12b5[0].Page1[0].List1[0].LI1[0].List1[0].LI6[0].FillText90[0] (0.37 conf)
c_b_page_list_l_text_field__2 was MC-350A-12b5[0].Page1[0].List1[0].LI1[0].List2[0].TextField6[0] (0.40 conf)
c_b_page_list_l_fill_text__7 was MC-350A-12b5[0].Page1[0].List1[0].LI1[0].List2[0].LI1[0].FillText84[0] (0.37 conf)
c_b_page_list_l_fill_text__8 was MC-350A-12b5[0].Page1[0].List1[0].LI1[0].List2[0].LI2[0].FillText85[0] (0.37 conf)
c_b_page_list_l_fill_text__9 was MC-350A-12b5[0].Page1[0].List1[0].LI1[0].List2[0].LI3[0].FillText87[0] (0.37 conf)
c_b_page_list_l_fill_text__10 was MC-350A-12b5[0].Page1[0].List1[0].LI1[0].List2[0].LI4[0].FillText88[0] (0.37 conf)
c_b_page_list_l_fill_text__11 was MC-350A-12b5[0].Page1[0].List1[0].LI1[0].List2[0].LI5[0].FillText89[0] (0.37 conf)
c_b_page_list_l_fill_text__12 was MC-350A-12b5[0].Page1[0].List1[0].LI1[0].List2[0].LI6[0].FillText90[0] (0.37 conf)
c_b_page_list_l_text_field__3 was MC-350A-12b5[0].Page1[0].List1[0].LI1[0].List3[0].TextField6[0] (0.40 conf)
c_b_page_list_l_fill_text__13 was MC-350A-12b5[0].Page1[0].List1[0].LI1[0].List3[0].LI1[0].FillText3[0] (0.37 conf)
c_b_page_list_l_fill_text__14 was MC-350A-12b5[0].Page1[0].List1[0].LI1[0].List3[0].LI2[0].FillText4[0] (0.37 conf)
c_b_page_list_l_fill_text__15 was MC-350A-12b5[0].Page1[0].List1[0].LI1[0].List3[0].LI3[0].FillText6[0] (0.37 conf)
c_b_page_list_l_fill_text__16 was MC-350A-12b5[0].Page1[0].List1[0].LI1[0].List3[0].LI4[0].FillText7[0] (0.37 conf)
c_b_page_list_l_fill_text__17 was MC-350A-12b5[0].Page1[0].List1[0].LI1[0].List3[0].LI5[0].FillText7[0] (0.37 conf)
c_b_page_list_l_fill_text__18 was MC-350A-12b5[0].Page1[0].List1[0].LI1[0].List3[0].LI6[0].FillText9[0] (0.37 conf)
c_b_page_list_l_text_field__4 was MC-350A-12b5[0].Page1[0].List1[0].LI1[0].List4[0].TextField6[0] (0.40 conf)
c_b_page_list_l_fill_text__19 was MC-350A-12b5[0].Page1[0].List1[0].LI1[0].List4[0].LI1[0].FillText3[0] (0.37 conf)
c_b_page_list_l_fill_text__20 was MC-350A-12b5[0].Page1[0].List1[0].LI1[0].List4[0].LI2[0].FillText4[0] (0.37 conf)
c_b_page_list_l_fill_text__21 was MC-350A-12b5[0].Page1[0].List1[0].LI1[0].List4[0].LI3[0].FillText6[0] (0.37 conf)
c_b_page_list_l_fill_text__22 was MC-350A-12b5[0].Page1[0].List1[0].LI1[0].List4[0].LI4[0].FillText7[0] (0.37 conf)
c_b_page_list_l_fill_text__23 was MC-350A-12b5[0].Page1[0].List1[0].LI1[0].List4[0].LI5[0].FillText7[0] (0.37 conf)
c_b_page_list_l_fill_text__24 was MC-350A-12b5[0].Page1[0].List1[0].LI1[0].List4[0].LI6[0].FillText9[0] (0.37 conf)
c_b_page_num_fill_text__1 was MC-350A-12b5[0].Page1[0].PageNum[0].FillText31[0] (0.42 conf)
c_b_page_num_fill_text__2 was MC-350A-12b5[0].Page1[0].PageNum[0].FillText32[0] (0.42 conf)

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The Legal Innovation & Technology Lab's Form Explorer Beta @ Suffolk Law School Last updated 2023-04-02

Additional Medical Service Providers Attachment to Petition for Approval of Compromise of Claim or Action or Disposition of Proceeds of Judgment

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The Legal Innovation & Technology Lab's Form Explorer ^Beta @ Suffolk Law School Last updated 2023-04-02