Request For Reconsideration Of Summary Rating By The Administrative Director {DWC-AD 103 (DEU)}

DWC-AD form103 (DEU), REQUEST FOR RECONSIDERATION OF SUMMARY RATING BY THE ADMINISTRATIVE DIRECTOR, This form may be used by an unrepresented employee or his or her employer to request that the Administrative Director determine whether a permanent disability rating issued by the Disability Evaluation Unit should be reconsidered pursuant to Labor Code section 4061(g). A request for reconsideration may be granted if it is shown that the Qualified Medical Evaluator (QME) or Primary Treating Physician (PTP) has failed to address all issues, failed to completely address issues, failed to follow the medical evaluation procedures promulgated by the Administrative Director, or if the rating was incorrectly calculated. This procedure is applicable only to injuries occurring on or after 1/1/91. Please verify that you sent a copy of this request to the other party (employee or claims administrator) by filling out the proof of service below after reading the instructions on the reverse side. This request must be submitted within thirty (30) days of receipt of the rating. (Rev. 11/2008)