State of California Division of Workers' Compensation - Medical Unit Additional Panel Request-8 Cal. Code of Regulations section 31.7 (Please print or type) Requesting Party (Required) Original panel number (Required) Claim number (Required) Joint request Applicant's Attorney/Injured Worker Defense Attorney/Claims Administrator Employee first name (Required) Middle Initial Employee last name (Required) EAMS number (Required if a case is filed) Reason for the additional panel request (Required) A written agreement between the parties in a represented case. (Please attach a signed joint letter or jointly sign the bottom of this form) The acupuncturist QME selected advised the parties that disability is in issue and a QME in a different specialty is necessary. (Please attach copy of the letter from the AME/QME.) Indicate the specialties you are requesting. Each specialty request must be justified by the reason listed above. Specialty to be issued Specialty to be issued Specialty to be issued Date of Request: (mm/dd/yyyy) Name of Requestor (Required) Signature of Requestor: Requestor Address (Required) State (Required) Zip Code (Required) Name of Requestor Signature of Requestor: Requestor Address State Zip Code QME form 31.7(10/2013) American LegalNet, Inc. www.FormsWorkFlow.com Declaration of Service I declare that I am a resident of or employed in the county where the mailing took place. I am over the age of eighteen years and I am not a party to this case, my business or residence address is: , I served this Additional Panel Request form, the original, or a true and correct copy of the original, which is attached, on each of the persons or firms named below, by placing it in a sealed envelope, addressed to the person or firm named below, and by: A depositing the sealed envelope with the U. S. Postal Service with the postage fully prepaid. placing the sealed envelope for collection and mailing following our ordinary business practices. I am readily familiar with this business's practice for collecting and processing correspondence for mailing. On the same day that correspondence is placed for collection and mailing, it is deposited in the ordinary course of business with the U. S. Postal Service in a sealed envelope with postage fully prepaid. placing the sealed envelope for collection and overnight delivery at an office or a regularly utilized drop box of the overnight delivery carrier. placing the sealed envelope for pick up by a professional messenger service for service. (Messenger must return to you a completed declaration of personal service.) personally delivering the sealed envelope to the person or firm named below at the address shown below. On B C D E Method of Service Person or firm served Street Address City State Zip Code Method of Service Person or firm served Street Address City State Zip Code Method of Service Person or firm served Street Address City State Zip Code Method of Service Person or firm served 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. Date: Type or print name at , California. Signature _____________________________________________ QME form 31.7(10/2013) American LegalNet, Inc. www.FormsWorkFlow.com QME Specialty Codes MD/DO Specialty Codes MAI MDE MEM MFP MPM MHH MMM MMV MME MMG MMH MMI MMO MMN MMP MMR MNB MPN MNS MOG MPO MOS MTO MPA MHA MPR MPD MSY MSG MTS MTT MUU Allergy & Immunology Dermatology Emergency Medicine Family Practice General Preventive Medicine Surgery - Hand Internal Medicine Internal Medicine - Cardiovascular Disease Internal Medicine ­ Endocrinology Diabetes & Metabolism Internal Medicine - Gastroenterology Internal Medicine - Hematology Internal Medicine - Infectious Disease Internal Medicine - Medical Oncology Internal Medicine - Nephrology Internal Medicine - Pulmonary Disease Internal Medicine - Rheumatology Spine Neurology Neurological Surgery (other than Spine) Obstetrics & Gynecology Occupational Medicine Orthopaedic Surgery (other than Spine or Hand) Otolaryngology Pain Medicine Pathology Physical Medicine & Rehabilitation Psychiatry (other than Pain Medicine) Surgery (other than Spine or Hand) Surgery - General Vascular Thoracic Surgery Toxicology Urology ACA DCH DEN OPT POD PSY PSN NON-MD/DO Specialty Codes Acupuncture Chiropractic Dentistry Optometry Podiatry Psychology Psychology - Clinical Neuropsychology Do Not file this page with your additional panel request! QME form 31.7(10/2013) American LegalNet, Inc. www.FormsWorkFlow.com