Free Request For QME panel under Labor Code Section 4062.2 – represented - California



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Excerpt: State of California DIVISION OF WORKERS' COMPENSATION - MEDICAL UNIT REQUEST FOR QME PANEL UNDER LABOR CODE 4062.2 REPRESENTED (Please print or type) Request date (Required): Date of Injury (Required): Specialty Requested (3 letter code required): Print Form Reset Form Claim Number (Required): Specialty of treating physician: Opposing party's spec
State of California DIVISION OF WORKERS' COMPENSATION - MEDICAL UNIT REQUEST FOR QME PANEL UNDER LABOR CODE 4062.2 REPRESENTED
(Please print or type)
Request date (Required): Date of Injury (Required): Specialty Requested (3 letter code required):

Print Form Reset Form

Claim Number (Required):

Specialty of treating physician:

Opposing party's specialty preference:

Requesting party (Check one box only) Applicant's Attorney(or injured employee) Defense Attorney /Claims Administrator

Reason QME panel is being requested (Read attachment, `How to Request a QME') (Check one box only):
4060 (compensability exam) 4061 (permanent impairment or disability dispute) 4062 Injured employee only (medical treatment determination, UR dispute or other 4062 reason ) 4062 Claims administrator only (non treatment medical determination or non-UR reason under 4062) 4061 and 4062 dispute (medical treatment and permanent impairment or disability dispute) If the claims administrator is requesting a 4062 panel explain the reason for the request below:

You must attach a copy of your written proposal identifying a disputed issue and naming one or more physicians to be an AME. Answer each question below:
Has this claim been denied? Yes No Has any body part in this claim been accepted? Yes No If yes, indicate the date of the denial
Does dispute involve an MPN :

Continuity or Transfer of Care

Permanent Disability, Future Medical, UR decision

Diagnosis/Treatment ?

Employee Information
First Name: Street Address : City: State: Zip Code:
Daytime Phone No:

Middle Initial:

Last Name:

If currently living outside of state, enter the California city and zip code on date of injury: If never resided in state, enter the California city and zip code for evaluation:

Employee's Attorney
First Name Law Firm Name Address/PO Box (Please leave blank spaces between numbers, names or words) City
QME Form 106 (rev. Feb 2009)

Last Name

Firm Number

State

Zip Code

Phone No
(Continue form on next page)

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Claim Number: Employer and Claims Administrator Information
Employer: Claims Administrator Name: Adjustor name: Street Address or P.O. Box: City: State: Zip Code: Phone Number:

Defendant's Attorney
First Name Law Firm Name Address/PO Box (Please leave blank spaces between numbers, names or words) City State Zip Code Phone Number Last Name Firm Number

Prior QME Panel Information (Answer all that apply)
Has the employee ever received a QME panel before? If yes, did the employee ever see any QME from that panel? If yes, has that claim been settled or resolved? If yes, name of QME seen:
Date of Injury: Panel Number (If known): Body parts: Yes Yes Yes No No No Unknown Unknown Unknown Specialty: Date of Exam:

Is that QME available now:

Yes

No

Unknown

The completed form must be mailed to: Division of Workers' Compensation-Medical Unit P.O. Box 71010, Oakland, Ca 94612 (510) 286-3700 or (800) 794-6900
Date: Print Name of Requestor: Signature

Note: The party submitting this form must attach a copy of the written proposal identifying a disputed issue and naming one or more physicians to be a AME.
QME Form 106 (rev. Feb 2009)

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For Use with the QME Panel Request Form 106
MD/DO SPECIALTY CODES
MAI MDE MEM MFP MPM MHH MMM MM V MME MMG MMH MMI MMN MMP MMR MNB MPN MNS MOG MPO MMO MOP MOS MTO MPA MHA MPR MPS MPD MSY MSG MTS MTT MUU Allergy and Immunology Dermatology Emergency Medicine Family Practice General Preventive Medicine Hand Internal Medicine Internal Medicine - Cardiovascular Disease Internal Medicine Endocrinology Diabetes and Metabolism Internal Medicine - Gastroenterology Internal Medicine - Hematology Internal Medicine - Infectious Disease Internal Medicine - Nephrology Internal Medicine - Pulmonary Disease Internal Medicine - Rheumatology Spine Neurology Neurological Surgery (other than Spine) Obstetrics and Gynecology Occupational Medicine Oncology Orthopaedic Surgery Internal , Medicine or Radiology Ophthalmology Orthopaedic Surgery (other than Spine or Hand) Otolaryngology Pain Medicine Pathology Physical Medicine & Rehabilitation Plastic Surgery (other than Hand) Psychiatry (other than Pain Medicine) Surgery (other than Spine or Hand) Surgery - General Vascular Thoracic Surgery Toxicology Urology

NON -MD/DO SPECIALTY CODES
ACA DCH DEN OPT POD PSY PSN Acupuncture Chiropractic Dentistry Optometry Podiatry Psychology Psychology - Clinical Neuropsychology

QME Form 106 (rev. Feb 2009)

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File Size: 516.8 kB
Pages: 3
Date: January 22, 2009
File Format: PDF
State: California
Category: Workers Compensation
Word Count: 706 Words, 4,493 Characters
Page Size: Letter (8 1/2" x 11")
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URL

http://www.dir.ca.gov/dwc/FORMS/QMEForms/QMEForm106.pdf