Free Microsoft Word - QME Form 112 on112408 clean - California

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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

QME/AME REPORT TIME FRAME EXTENSION REQUEST
(Send to DWC Medical Unit 5 or more days before report is due.)



Request for 30 day extension Reason ___ Lab or test results not received. Type of test: ___ Report of consulting physician not received. Specialist type: Request for 15 day extension Reason ___ Medical emergency of the evaluator or evaluator family member. ___ Death in evaluator's family. ___ Natural disaster/other community catastrophe interrupted office. Request extension for supplemental report (maximum 30 days)

Date of Physical Evaluation:

Date Report will be served:

________________________________________________________________________________________________ Employee's Name Claims Administrator QME Name
(PRINT/TYPE)

Date of Injury Claim No. Panel No. CA Lic. No. Date City/Zip Fax

QME Signature Street Address Telephone

File this form with the Division of Workers' Compensation-Medical Unit 5 days before your report is due to be served on the parties and send a copy of this form to the employee and claims administrator. The QME may not be entitled to payment for evaluations which are not submitted in a timely manner (Labor Code § 4062.5). Review 8 Cal. Code Regs. § 38(h) regarding extension of time for supplemental report. If you need further information, please call us at (510) 286-3700 or 1-800-794-6900. FOR DWC USE ONLY ( ) Extension approved Medical Director:
QME Form 112 (rev. February 2009)

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) Extension denied and notice mailed to evaluator and parties Date