California > Workers Comp > General
Denial Of Time Extension IMC-114 - California
| Denial Of Time Extension 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 DEPARTMENT OF INDUSTRIAL RELATIONS INDUSTRIAL MEDICAL COUNCIL DWC - Medical Unit P.O. Box 420603 San Francisco, CA 94142 Tel. No.: (650) 737-2700 or 1-(800) 794-6900 Fax No.: (650) 737-2711 Arnold Schwarzenegger, Governor TO: Evaluator's Name DATE: Injured worker's Name Date of Injury: Case Number: Claim Number: Panel Number: DENIAL OF TIME EXTENSION Your request for time extension for medical evaluation report submission has been denied for the following reason(s): The report is due within 45 days (for injuries occurring on or after 1/1/91 up to 12/31/93) or 30 days (for injuries occurring on or after 1/1/94) of the appointment. Please note Labor Code Section 4062.5 states that the QME is not entitled to payment for evaluations which are not submitted in a timely manner and rejected by the applicant. The injured worker now has the option of accepting the late report or requesting a replacement. IMC FORM 114 Rev. 3/01/00 Authority cited: Reference: IMC Regs-Forms Sections 139, 139.2, Labor Code. Sections 139.2, 4060, 4061, 4062, 4062.5, Labor Code. American LegalNet, Inc. www.USCourtForms.com
|
|||||||
