Request For Factual Correction Of An Unrepresented Panel QME {QME 37}

QME Form 37 - REQUEST FOR FACTUAL CORRECTION OF AN UNREPRESENTED PANEL QME REPORT. This form is used in California workers’ compensation cases when an unrepresented injured worker or claims administrator believes a Panel Qualified Medical Evaluator (QME) report contains factual errors. Issued by the Division of Workers’ Compensation (DWC), this form allows a party to request correction of verifiable factual inaccuracies—such as dates, work history, or identifying information—before the report is rated by the Disability Evaluation Unit (DEU). The request must be made within 30 days of receipt of a comprehensive medical-legal report finding permanent disability. The form requires detailed employee, employer, claims administrator, and QME information, along with a Declaration of Service. No additional medical evidence may be attached. www.FormsWorkflow.com