Request For QME Panel Under Labor Code 4062.1 Unrepresented {QME 105} | Pdf Fpdf Doc Docx | California

 California   Workers Comp   General 
Request For QME Panel Under Labor Code 4062.1 Unrepresented {QME 105} | Pdf Fpdf Doc Docx | California

Last updated: 3/30/2016

Request For QME Panel Under Labor Code 4062.1 Unrepresented {QME 105}

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Description

QME Form 105 - REQUEST FOR QUALIFIED MEDICAL EVALUATOR PANEL (Unrepresented Employee). This form is used in California workers’ compensation cases when an unrepresented injured employee (or the claims administrator) requests a Qualified Medical Evaluator (QME) panel from the Division of Workers’ Compensation (DWC) Medical Unit. This form applies when there is a medical dispute, such as whether an injury is work-related, objections to a primary treating physician’s opinions, or disputes over additional body parts. The request requires selection of a single medical specialty and completion of an attached Proof of Service. The completed form must be served on the opposing party and mailed to the DWC Medical Unit. www.FormsWorkflow.com

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