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Request For QME Panel Under Labor Code 4062.1 Represented (Attachment) QME 106a - California
| Request For QME Panel Under Labor Code 4062.1 Represented (Attachment) Form. This is a California form and can be used in General Workers Comp . |
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State of California DIVISION OF WORKERS' COMPENSATION - MEDICAL UNIT REQUEST FOR QME PANEL UNDER LABOR CODE § 4062.2 REPRESENTED Date of Injury(Required): (For dates of injury on or after 1/1/2013 Please print or type) Specialty of Treating Physician (Required): Claim Number (Required): Specialty Requested (Required): Opposing Party's Specialty Preference (If known): Requesting party (Required: check one box only) Applicant's Attorney Defense Attorney /Claims Administrator Reason QME panel is being requested (Required: check one box only) § 4060 (compensability exam) § 4061 (permanent disability dispute) § 4062 (non medical treatment dispute under 4062) Employee Information (Required) First Name: Mailing Address: Zip Code: Middle Initial: City: Last Name: State: If currently not living in state, enter the California zip code on date of injury: If never resided in state, enter the California zip code agreed on for the evaluation: Answer each question below (Required) Has the employee ever had an AME/QME exam before? If yes, has that claim been settled or resolved? Is this a dispute about a current need for medical treatment? Is this a dispute over an additional body part ? Name of the Primary Treating Physician: Describe the nature of the dispute that requires resolution: Yes Yes Yes Yes No No No No If the employee has seen an AME/ QME for this injury, provide the information below: Name of AME/QME seen: Date of Exam: Date of Report being objected to: Employee's Attorney (Required) First Name Last Name Law Firm Name Address/PO Box (Please leave blank spaces between numbers, names or words) City QME Form 106a (1/2013) State Zip Code Phone Number (Continue form on next page) American LegalNet, Inc. www.FormsWorkFlow.com Page 1 of 3 Claim Number: Employer and Claims Administrator Information Employer: Claims Administrator Company Name: Claims Adjustor Name: Street Address or P.O. Box: City: State: Zip Code: Phone Number: Defendant's Attorney First Name Last Name Law Firm Name Address/PO Box (Please leave blank spaces between numbers, names or words) City State Zip Code Phone Number Date: Print Name of Requestor Signature of Requestor 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 Note: The party submitting this form must attach a copy of the written objection to an opinion of a treating physician identifying an issue in dispute. Page 2 of 3 QME Form 106a (1/2013) American LegalNet, Inc. www.FormsWorkFlow.com For Use with the QME Panel Request Form 106a MD/DO SPECIALTY CODES MAI MDE MEM MFP MPM MHH MMM MMV 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 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 Do not file this page with your form! QME Form 106a (1/2013) American LegalNet, Inc. www.FormsWorkFlow.com
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