California > Workers Comp > General
Replacement Panel Request QME 31.5 Opt. - California
| Replacement Panel Request Form. This is a California form and can be used in General Workers Comp . |
|
||||||
 Get this form for FREE as a print-only pdf |
|||||||
|
State of California DIVISION OF WORKERS' COMPENSATION MEDICAL UNIT REPLACEMENT PANEL REQUEST TITLE 8, CALIFORNIA CODE OF REGULATIONS § 31.5 (Please print or type) If anything has changed including parties, addresses, and represented status, Please attach the information on a separate sheet of paper Date of Request: (Required) Original Panel No.: (Required) __________________ ___________________________ Requesting Party: (Check one box only) Applicant's Attorney/Injured Worker Defense Attorney/Claims Administrator Claim No.: (Required) ____________________ Injured Worker: (Required) Name of QME(s) to replace: ________________________ First Name ___________________________ Last Name Reason #: _____ Reason #: _____ Reason #: _____ 1. ____________________________ 2. ____________________________ 3. Entire Panel List Reason for Replacement (all references are to Title 8, CCR 31.5 unless otherwise noted): You must attach relevant supporting documentation. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. QME on the panel issued does not practice in the specialty requested. (a) (1) A QME on the panel issued cannot schedule an appointment within 60 90 days. (a)(2) (Please indicate date of initial request for an appointment) The injured worker has changed his or her residence address. (a)(3) New Address: __________________________________________________________ A physician on the QME panel is a member of the same group practice as defined by Labor Code § 139.3 as another QME on the panel. (a)(4) (Please attach evidence of form of business entity of group practice) The QME is unavailable pursuant to § 33 (Unavailability of the QME). (a)(5) and § 33 The evaluator who previously reported in the case is no longer available. (a)(6) A QME named on the panel is currently, or has been, the employee's primary treating physician or secondary physician for the injury currently in dispute. (a)(7) Parties agree to a new panel in the region of the employee's workplace. (a)(8) (Please attach agreement) Workplace Zip Code: ________ Good cause for a different specialty due to medical nature of injury. (a)(9) (Attach medical documentation) Inappropriate specialty for disputed medical issues. (a)(10) (Attach medical documentation) No appointment notification (Form 110). (a) (11) and § 34 (Attach statement explaining how and when you became aware of the violation) Late report. (a) (12) and § 38 (Attach evidence of lateness) Disqualifying conflict of interest (a) (13) and § 41.5 (Attach evidence of conflict) AD order for an additional QME evaluation. (a)(14) and § 10164 (c) (Attach AD order) Selected QME fails to provide either a complete medical evaluation or a written statement explaining why the evaluator feels he or she is not medically qualified to address disputed issues. (a)(15) No QME used from a panel issued over 24 months ago. (a) (16) Represented parties have each struck a QME from the panel and the last QME may be replaced based on any of the reasons above. (c) Requestor's Signature ____________________________________ American LegalNet, Inc. www.FormsWorkFlow.com Name of Requestor and Phone Number (Print) _______________________________________ QME Form 31.5 Opt. Rev. May 2010
|
|||||||
