Free Request For QME panel under Labor Code Section 4062.1 – unrepresented - California

State of California DIVISION OF WORKERS' COMPENSATION - MEDICAL UNIT REQUEST FOR QME PANEL UNDER LABOR CODE § 4062.1 UNREPRESENTED
(Please print or type)
Request date (Required): Date of Injury (Required): Claim Number (Required):

Print Form Reset Form

Specialty Requested (Required):
(use 3 letter code only)

Requesting party (Check one box only):
Unrepresented Injured Employee Claims Administrator, if none, Employer Defense Attorney

Reason QME panel is being requested (Check one box only):
§ 4060 (compensability exam) § 4061 (permanent impairment or disability dispute)

§ 4062 Injured employee only (medical treatment determination, UR dispute or other 4062 reason ) § 4062 Claims administrator only (non treatment medical determination or non-UR reason under 4062) §§ 4061 and 4062 dispute (medical treatment and permanent impairment or disability dispute) If the Claims administrator is requesting a 4062 panel explain the reason for the request:

Answer each question below:
Has this claim been denied? Yes No Has any body part in this claim been accepted? Yes No

If yes, indicate the date of the denial
Did notice to injured employee state employer requests an evaluation to determine compensability?(Attach copy of notice)
Does dispute involve an MPN :

Yes

No

Continuity or Transfer of Care

Permanent Disability, Future Medical, UR decision

Diagnosis/Treatment ?

Employee Information
First Name: Street Address : City: State: Zip Code: Daytime Phone No: Middle Initial: Last Name:

If you now live out of state, list the California city and zip code of your residence when injured: If you never resided in California, list the California zip code in which you would like to be evaluated:

Employer and Claims Administrator Information
Employer: Claims Administrator Name: Adjustor name: Street Address or P.O. Box: City:
QME Form 105 (rev. February 2009)

State:

Zip Code:

Phone No.
(Continue form on next page)

Page 1 of 3

Claim Number: Prior QME Panel Information (Answer all that apply)
Has the employee ever received a QME panel before? If yes, did the employee ever see any QME from that panel? If yes, has that claim been settled or resolved? If yes, name of QME seen:
Date of Injury: Panel Number (If known): Body parts Yes Yes Yes No No No Unknown Unknown Unknown Specialty: Date of Exam:

Is that QME available now:

Yes

No

Unknown

The completed form must be mailed to: Division of Workers' Compensation-Medical Unit P.O. Box 71010, Oakland, Ca 94612 (510) 286-3700 or (800) 794-6900
Date:

Print Name of Requestor

Signature of Injured Employee

Note: Each employer or claims administrator submitting this form to request a QME panel must attach a copy of the correspondence and required notices sent to the injured employee with the panel request form

QME Form 105 (rev. February 2009)

Page 2 of 3

For Use with the QME Panel Request Form 105
MD/DO SPECIALTY CODES
MAI MDE MEM MFP MPM MHH MMM MM V MME MMG MMH MMI MMN MMP MMR MNB MPN MNS MOG MPO MMO MOP MOS MTO MPA MHA MPR MPS MPD MSY MSG MTS MTT MUU Allergy and Immunology Dermatology Emergency Medicine Family Practice General Preventive Medicine Hand Internal Medicine Internal Medicine - Cardiovascular Disease Internal Medicine ­ Endocrinology Diabetes and Metabolism Internal Medicine - Gastroenterology Internal Medicine - Hematology Internal Medicine - Infectious Disease Internal Medicine - Nephrology Internal Medicine - Pulmonary Disease Internal Medicine - Rheumatology Spine Neurology Neurological Surgery (other than Spine) Obstetrics and Gynecology Occupational Medicine Oncology ­ Orthopaedic Surgery Internal , Medicine or Radiology Ophthalmology Orthopaedic Surgery (other than Spine or Hand) Otolaryngology Pain Medicine Pathology Physical Medicine & Rehabilitation Plastic Surgery (other than Hand) Psychiatry (other than Pain Medicine) Surgery (other than Spine or Hand) Surgery - General Vascular Thoracic Surgery Toxicology Urology

NON -MD/DO SPECIALTY CODES
ACA DCH DEN OPT POD PSY PSN Acupuncture Chiropractic Dentistry Optometry Podiatry Psychology Psychology - Clinical Neuropsychology

QME Form 105 (rev. February 2009)

Page 3 of 3