Qualified Or Agreed Medical Evaluator Findings Summary Form {QME 111}

QME Form 111 - QUALIFIED MEDICAL EVALUATOR'S FINDINGS SUMMARY FORM UNREPRESENTED INJURED EMPLOYEE CASES ONLY. This form is used in unrepresented injured worker cases to summarize the medical findings from a comprehensive medical-legal evaluation. The form records employee and claims administrator information, key event dates, and the evaluator’s conclusions on disputed medical issues such as causation, permanent and stationary status, impairment, apportionment, medical treatment needs, and work capacity. It also documents the clinical basis for these conclusions, including subjective complaints, examination findings, diagnostic testing, diagnoses, medical record review, and any consultation with other physicians. The form includes a declaration of service confirming that both the medical-legal report and the completed summary were properly served on required parties. www.FormsWorkflow.com