Request For QME Panel {QME 106}

QME Form 106 - REQUEST FOR QME PANEL UNDER LABOR CODE § 4062.2 REPRESENTED. This form is used in California workers’ compensation cases when the injured employee is represented by an attorney and a medical dispute requires evaluation by a Qualified Medical Evaluator (QME). This version applies to injuries occurring prior to January 1, 2005 and is submitted to the Division of Workers’ Compensation (DWC) Medical Unit. The form is used to request a QME panel for disputes involving compensability, permanent disability, or non-medical treatment issues. It requires identification of the treating physician’s specialty, the specialty requested, details of the dispute, and disclosure of any prior AME or QME evaluations. A Declaration of Service is mandatory, and a written objection to the treating physician’s opinion must be attached. www.FormsWorkflow.com