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Additional Panel Request QME 31.7 - California
| Additional Panel Request 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 ADDITIONAL PANEL REQUEST TITLE 8, CALIFORNIA CODE OF REGULATIONS § 31.7 (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 Number: (Required) Requesting Party: (Check one box only) ____________ _____________________________ Claim Number: (Required) Applicant's Attorney/Injured Worker Defense Attorney/Claims Administrator Joint Request ________________________ Injured Worker: (Required) ________________________ First Name _______________________ Last Name Specialty (ies): (Required) (Use the three-letter code) ____________________________ ____________________________ ___________________________ Reason for Additional Panel (all references are to Title 8, CCR 31.7 unless otherwise noted): Judge's Order (Please attach a copy of the order). (b)(1) The AME or QME selected advised the parties and Medical Director there are issues which need to be addressed that are outside his or her clinical competence. (Please attach copy of AME/QME report) (b)(2) A written agreement between the parties in a represented case. (Please attach a signed joint letter or jointly sign the bottom of this form) (b)(3) Agreement of the parties and an Information and Assistance Officer in an unrepresented case. (Please attach I&A recommendation or have I&A Officer sign on the line below) (b)(4) Name of Requestor (Print) _________________________________________ Name of Requestor (Print) _________________________________________ Name of I&A Officer (Print) _________________________________________ Requestor's Signature _________________________________________ Requestor's Signature _________________________________________ I&A Officer's Signature _________________________________________ QME Form 31.7 Opt. Rev. May 2010 American LegalNet, Inc. www.FormsWorkFlow.com
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