Denial Of Time Extension
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Denial Of Time Extension Form. This is a California form and can be use in General Workers Comp.
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Tags: Denial Of Time Extension, IMC-114, California Workers Comp, General
Arnold Schwarzenegger, Governor
STATE OF CALIFORNIA
DEPARTMENT OF INDUSTRIAL RELATIONS
INDUSTRIAL MEDICAL COUNCIL
DWC - Medical Unit
P.O. Box 420603
San Francisco, CA 94142
Tel. No.: (650) 737-2700 or 1-(800) 794-6900 Fax No.: (650) 737-2711
TO:
DATE:
Evaluator's Name
Injured worker's Name
Date of Injury:
Case Number:
Claim Number:
Panel Number:
DENIAL OF TIME EXTENSION
Your request for time extension for medical evaluation report submission has been denied for
the following reason(s):
The report is due within 45 days (for injuries occurring on or after 1/1/91 up to 12/31/93) or 30
days (for injuries occurring on or after 1/1/94) of the appointment. Please note Labor Code
Section 4062.5 states that the QME is not entitled to payment for evaluations which are not
submitted in a timely manner and rejected by the applicant. The injured worker now has the
option of accepting the late report or requesting a replacement.
IMC FORM 114 Rev. 3/01/00
Authority cited:
Reference:
Sections 139, 139.2, Labor Code.
Sections 139.2, 4060, 4061, 4062, 4062.5, Labor Code.
IMC Regs-Forms
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