State of California, Division of Workers' Compensation REQUEST FOR QUALIFIED MEDICAL EVALUATOR PANEL (Unrepresented Employee) TO REQUEST A QUALIFIED MEDICAL EVALUTOR (QME) PANEL FOR AN UNREPRESENTED EMPLOYEE: 1. Complete this form (print or type the information). Sign and date at bottom. 2. If the request is made to determine if the injury is work-related, include a copy of the claims administrator's notice that the claim was denied, or a copy of the claims administrator's request for an evaluation. 3. Complete the attached Proof of Service. 4. For Employee: Mail the completed signed form and Proof of Service to: Division of Workers' Compensation ­ Medical Unit P.O. Box 71010, Oakland, CA 94612 (510) 286-3700 or (800) 794-6900 5. For Employee: Mail or deliver a signed copy of the form and Proof of Service to your Claims Administrator. 6. For Claims Administrator/Defense Attorney: Mail the completed signed form, attach a copy of the written objection to an opinion of a treating physician, and Proof of Service, to the Medical Unit with a copy served to the Employee. Panel Request Information : Date of Injury: _____________ Claim Number:_________________ Specialty Requested:_____________________ (Select only ONE specialty) Requesting Party: Employee Claims Administrator Defense Attorney Reason for QME Panel Request (check one): To determine if the injury is work-related (attach claims administrator's notice that claim was denied or a copy of the claims administrator's request for an evaluation). Objection to Primary Treating Physician's determination regarding temporary disability, permanent disability, or the need for future medical care. Work injury claim is accepted for one or more body parts, there is a dispute over additional body parts. Other (specify non-medical treatment dispute): _______________________________________________________ Employee Information First Name:__________________________ Middle Initial:_____ Last Name: _________________________________ Street Address or P.O. Box: __________________________________________________________________________ City:_________________________ State __________ Zip Code:_____________________________ If currently not living in state, enter the California zip code on date of injury:________________________ If never resided in state, enter the California zip code agreed on for the evaluation: __________________ Employer/Claims Administrator Information Employer:_________________________________________ Zip Code of Employer:_______________________ Claims Administrator Company Name:___________________ Adjuster/Contact Name (if known):___________________ Street Address or P.O. Box:____________________________________________________________ City:_________________________ State:_____ Zip Code:___________ Phone No.:__________________________ Requestor Signature: QME Form 105 (rev. 09/15) Date:____________________________________ Page 1 American LegalNet, Inc. www.FormsWorkFlow.com PROOF OF SERVICE Instructions: 1.Complete the Proof of Service. 2. For Employee: Mail the completed signed form and Proof of Service to: Division of Workers' Compensation ­ Medical Unit P.O. Box 71010, Oakland, CA 94612 (510) 286-3700 or (800) 794-6900 3. For Employee: Mail or deliver a signed copy of the form and Proof of Service to your Claims Administrator. 4. For Claims Administrator/Defense Attorney: Mail the completed signed form attach a copy of the written objection to an opinion of a treating physician, and Proof of Service, to the Medical Unit with a copy served to the Employee. I declare that I am a resident of or employed in the county of __________________, California; I am over the age of eighteen years. On ________________, I served the attached completed Form 105 on the following parties: by mail to: ______________________________________ Name of Employee or Claims Administrator ______________________________________ Street Address _______________________________________ City, State, Zip code by hand-delivery to: ______________________________________ Name ______________________________________ Street Address _______________________________________ City, State, Zip code I declare, under penalty of perjury under the laws of the State of California, that the foregoing is true and correct. Executed on _____________________, at _______________________, California Type or Print Name:__________________________________________ Signature:__________________________________________________ QME Form 105 (rev. 09/15) Page 2 American LegalNet, Inc. www.FormsWorkFlow.com For Use with the QME Panel Request Form 105 MD/DO SPECIALTY CODES MAA Anesthesiology MAI MPA MDE MAI Allergy & Immunology Pain Medicine Dermatology Dermatology ­ Allergy & Immunology MHH Orthopedic Surgery - Hand MTO Otolaryngology MHA Pathology MPR MPA MPS MHH MPD MPA MSY MHH MSG MTS Physical Medicine & Rehabilitation Physical Medicine & Rehabilitation ­ Pain Medicine Plastic Surgery (other than Hand) Plastic Surgery ­ Hand Psychiatry (other than Pain Medicine) Psychiatry ­ Pain Medicine Surgery (other than Spine or Hand) Surgery - Hand Surgery- General Vascular Thoracic Surgery MEM Emergency Medicine MTT MFP Emergency Medicine ­ Toxicology Family Practice MPM General Preventive Medicine MTT General Preventive Medicine ­ Toxicology MMM Internal Medicine MAI Internal Medicine- Allergy & Immunology MMV Internal Medicine ­ Cardiolvascular Disease MME Internal Medicine - Endocrinology Diabetes & Metabolism MMG Internal Medicine ­ Gastroenterology MMH Internal Medicine ­ Hematology MMI Internal Medicine ­ Infectious Disease MMO Internal Medicine ­ Medical Oncology MMN Internal Medicine ­ Nephrology MMP Internal Medicine ­ Pulmonary Disease MMR Internal Medicine ­ Rheumatology MPN Neurology MPA Neurology ­ Pain Medicine MNS Neurological Surgery (other than Spine) MNB Neurological Surgery ­ Spine MOG Obstetrics & Gynecology MOQ Medicine Otherwise Qualified MPO Occupational Medicine MTT Occupational Medicine ­ Toxicology MOP Ophthalmology MOS Orthopedic Surgery (other than Spine or Hand) MNB Orthopedic Surgery - Spine MUU Urology NON-MD/DO SPECIALTIES CODES ACA DCH DEN OPT POD PSY Acupuncture Chiropractic Dentistry Optometry Podiatry Psychology Do not file this page with your form! QME Form 105 (rev. 09/15) Page 3 American LegalNet, Inc. www.FormsWorkFlow.com