Notice Of Unavailability {QME 109}

QME Form 109 - QME NOTICE OF UNAVAILABILITY. This is a required California Division of Workers’ Compensation Medical Unit form that Qualified Medical Evaluators must file to declare periods when they are unavailable to accept panel assignments. The form must be submitted at least 30 days before the unavailability period unless good cause for late submission is documented. A QME who is unavailable may not schedule or perform any initial or follow-up evaluations during that period but may complete reports for examinations already performed. The form requires the QME’s identifying information, dates of unavailability, office locations affected, and a mandatory listing of all comprehensive medical-legal exams already scheduled during the requested period, or certification that none are scheduled. Extended unavailability exceeding 90 days without good cause may affect reappointment status. www.FormsWorkflow.com