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This is a California form that can be used for General within Workers Comp.
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STATE OF CALIFORNIA Division of Workers' Compensation Medical Unit P.O. Box 71010, Oakland, CA 94612 (510) 286-3700 or (800) 794-6900 QUALIFIED MEDICAL EVALUATOR'S FINDINGS SUMMARY FORM UNREPRESENTED INJURED EMPLOYEE CASES ONLY ________________________________________________________________________________________________ EMPLOYEE 1. Employee Name (First, Middle, Last) 4. Street Address City 2. Social Sec. No. (Optional) Zip 3. Date of Injury 5. Phone ________________________________________________________________________________________________________ CLAIMS ADMINISTRATOR (if none, enter Employer information) 6. Name 7. Street Address City Zip 8. Phone ________________________________________________________________________________________________________ EVENT DATES 9. Date of Appointment Call 10. Initial Examination Date 11. Date of Referral for Medical Testing/Consultation 12a. Date QME Report Served on all Parties 12b. Date(s) of all prior report(s) served by this QME? ________________________________________________________________________________________________________ DISPUTED MEDICAL ISSUES AND CONCLUSIONS 13. The following medical issues will be used to determine the injured employee's eligibility for workers' compensation benefits. (Check the appropriate box) Yes No Pending or Info. Not Sent a. Has the condition reached permanent and stationary status or maximum medical improvement? b. Is there permanent impairment/disability? c. Did work cause or contribute to the injury or illness? d. If permanent disability exists, is apportionment warranted? e. Is there a need for current or future medical care? f. Can this employee now return to his/her usual job? If yes: i. Without restrictions ii. With restrictions Yes No Yes No, If YES, Date: ________________ Yes No, If YES, Date: ________________ ________________________________________________________________________________________________________ BASIS FOR CONCLUSIONS (Check the appropriate box) Yes No Pending or Info. Not Sent 14. Are there subjective complaints? 15. Are there any abnormal physical or psychological examination findings? 16. Are impairments described and measured using: (For non-psyche injuries) the AMA Guides? (For psyche injuries) the GAF and 2005 PD Schedule? American LegalNet, Inc. www.FormsWorkflow.com QME Form 111 (rev. February 2009) Yes No Pending or Info. Not Sent 17. If the AMA Guides are used, are percentages of impairment stated? 18. Are there any relevant diagnostic test results (x-ray/laboratory)? 19. What are the diagnoses? (List) _________________________________________________________________________ 20. Were medical records reviewed? 21. Were other physicians consulted? 22. Are there any unresolved disputed issues beyond the scope of your licensure or clinical competence that should be addressed by an evaluator in a different specialty? 23. If the answer to # 22 is yes, what disputed issue(s)?_________________________________________________________ 24. Based on the answer in # 23, what specialty (or specialties)?___________________________________________ ________________________________________________________________________________________________________ QME 22. Signature:___________________________________________________________Date:__________________________ 23. Name:_____________________________________________________Specialty:_______________________________ 24. Street Address:______________________________________City:___________________________Zip:_____________ 25. Phone:_______________________________________ Cal. License No.:_______________________________________ Declaration of Service of Medical - Legal Report (Lab. Code § 4062.3(i)) I, ______________________________________________________________________________________, declare: (Print Name) 1. 2. 3. I am over the age of 18 and I am not a party to this case. My business address is :_________________________________________________________________________________________ On the date shown below, I served this QME Findings Summary Form with the original, or a true and correct copy of the original, comprehensive medical-legal report, which is attached, on each of the persons or firms named below, by placing it in a sealed envelope, addressed to the person or firm named below, and by: A B depositing the sealed envelope with the U. S. Postal Service with the postage fully prepaid. placing the sealed envelope for collection and mailing following our ordinary business practices. I am readily familiar with this business's practice for collecting and processing correspondence for mailing. On the same day that correspondence is placed for collection and mailing, it is deposited in the ordinary course of business with the U. S. Postal Service in a sealed envelope with postage fully prepaid. placing the sealed envelope for collection and overnight delivery at an office or a regularly utilized drop box of the overnight delivery carrier. placing the sealed envelope for pick up by a professional messenger service for service. (Messenger must return to you a completed declaration of personal service.) personally delivering the sealed envelope to the person or firm named below at the address shown below. C D E QME Form 111 (rev. February 2009) American LegalNet, Inc. www.FormsWorkflow.com Means of service: (For each addressee, Enter A E as appropriate) Date: Addressee and Address: ____________________ ____________________ ____________________ ____________________ When report addresses PD: ____________________ ________ ________ ________ ________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ ________ Disability Evaluation Unit, DWC,__________________________________________ I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Date Signed: ____________________________________ ___________________________________________________ (Signature of Declarant) _______________________________________________ (Print Name) INSTRUCTIONS FOR QME FORM 111 USE THIS FORM ONLY WHEN THE INJURED EMPLOYEE IS UNREPRESENTED To the QME: You are required by Labor Code section 4062.3(i) to summarize the medical findings from your comprehensive medical-legal eva
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