Free Microsoft Word - QME Form 109 clean - California

PRINT CLEAR
STATE OF CALIFORNIA DEPARTMENT OF INDUSTRIAL RELATIONS Division of Workers' Compensation - Medical Unit
P. O. Box 71010 Oakland, CA 94612 (510) 286-3700 or (800) 794-6900 Fax: (510) 622-3467

QME NOTICE OF UNAVAILABILITY
(Form must be filed 30 days prior to date of unavailability)

TO MEDICAL DIRECTOR, DWC: (Check the appropriate boxes to indicate that you will be unavailable for panel assignment for a period of 14 days to 90 days.)
Please accept this notice that I will be unavailable for qualified medical evaluation panel assignment from to (mm/dd/yyyy) (mm/dd/yyyy) I wish to resign from my appointment as a QME at all locations on file. Please remove my name from the List of Qualified Medical Evaluators. ============================================================================= The above information is for all of my QME office locations. The above information is only for the QME office location(s) listed below (or attached). Office Street Address City Office Street Address City Office Street Address City Zip Zip Zip

Signature Name (print/type)

Date Phone No.

CA. License No.

To complete this application, attach a list of all QME and AME examinations scheduled for the period of unavailability. For each case, state whether the exam is being rescheduled or whether you plan to complete the exam and report during the period of unavailability.
(Note: It is not an acceptable reason for unavailability that a QME does not intend to perform evaluations for unrepresented workers. A QME who is unavailable may not schedule or perform QME evaluation examinations (initial or follow up) until the QME returns to active status. A QME may complete reports for evaluation exams performed before becoming unavailable or supplemental reports. A QME who is unavailable for more than 90 days during the QME fee period without good cause may be denied reappointment. If this form is being filed less than 30 days before the QME is to become unavailable, attach a separate explanation of good cause for approving the late application.)

Send this completed form to: Division of Workers' Compensation-Medical Unit P.O. Box 71010 Oakland, CA 94612 (510) 286-3700 or (800) 794-6900 Fax (510) 622-3467
QME Form 109 (rev. February 2009)