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Request For QME Panel Under Labor Code 4062.1 Unrepresented (Attachment) QME 105a - California
| Request For QME Panel Under Labor Code 4062.1 Unrepresented (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 § 4062.1 UNREPRESENTED (For date of injury on or after 1/1/2013 Please print or type) Date of Injury (Required): Claim Number (Required): Specialty Requested (Required): Requesting party (Required) (Check one box only) Injured Employee Defense Attorney Claims Administrator Reason QME panel is being requested (Check one box only) § 4060 (compensability exam) § 4061 (permanent disability dispute) § 4062 (non medical treatment dispute under 4062) Employee Information (Required) First Name: Street Address or P.O. Box: City: State: Zip Code: Daytime Phone No: Middle Initial: Last Name: 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: Has the employee ever received a QME panel before? Name of QME seen: Has that claim been settled or resolved? Yes Yes No If yes, Panel Number (If known): Date of Exam: Date of Injury: Yes No No Is this a dispute about a current need for medical treatment? Employer and Claims Administrator Information (Required) Employer: Claims Administrator Company Name: Claims Examiner Name: Street Address or P.O. Box: City: State: Zip Code: Phone No. Defendant's Attorney First Name Law Firm Name Address/PO Box (Please leave blank spaces between numbers, names or words) City State Zip Code Phone Number Last Name 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: 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 105a (1/2013) American LegalNet, Inc. www.FormsWorkFlow.com For Use with the QME Panel Request Form 105a 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 105a (1/2013) American LegalNet, Inc. www.FormsWorkFlow.com
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