4906. (a) No charge, claim, or agreement for the legal services or
disbursements mentioned in subdivision (a) of Section 4903, or for
the expense mentioned in subdivision (b) of Section 4903, is
enforceable, valid, or binding in excess of a reasonable amount. The
appeals board may determine what constitutes a reasonable amount.
(b) No attorney or agent shall demand or accept any fee from an
employee or dependent of an employee for the purpose of representing
the employee or dependent of an employee in any proceeding of the
division, appeals board, or any appellate procedure related thereto
until the amount of the fee has been approved or set by the appeals
(c) Any fee agreement shall be submitted to the appeals board for
approval within 10 days after the agreement is made.
(d) In establishing a reasonable attorney's fee, consideration
shall be given to the responsibility assumed by the attorney, the
care exercised in representing the applicant, the time involved, and
the results obtained.
(e) At the initial consultation, an attorney shall furnish the
employee a written disclosure form promulgated by the administrative
director which shall clearly and prominently describe the procedures
available to the injured employee or his or her dependents. The
disclosure form shall describe this section, the range of attorney's
fees customarily approved by the appeals board, and the attorney's
fees provisions of Section 4064 and the extent to which an employee
may receive compensation without incurring attorney's fees. The
disclosure form shall include the telephone number of the
administrative director together with the statement that the employee
may receive answers at that number to questions concerning
entitlement to compensation or the procedures to follow to receive
compensation. A copy of the disclosure form shall be signed by the
employee and the attorney and sent to the employer, or insurer or
third-party administrator, if either is known, by the attorney within
15 days of the employee's and attorney's execution thereof.
(f) The disclosure form set forth in subdivision (e) shall
contain, prominently stated, the following statement:
"Any person who makes or causes to be made any knowingly false or
fraudulent material statement or representation for the purpose of
obtaining or denying worker's compensation benefits or payments is
guilty of a felony."
(g) The employee, the insurer, the employer, and the attorneys for
each party shall sign and file with the board a statement, with the
application or answer, under penalty of perjury that they have not
violated Section 139.3 and that they have not offered, delivered,
received, or accepted any rebate, refund, commission, preference,
patronage dividend, discount, or other consideration, whether in the
form of money or otherwise, as compensation or inducement for any
referred examination or evaluation.