Notice Of Late QME Report
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Notice Of Late QME Report Form. This is a California form and can be use in General Workers Comp.
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Tags: Notice Of Late QME Report, IMC-7, California Workers Comp, General
TO: EMPLOYEE'S NAME Date Case Number NOTICE OF LATE QME REPORT Your QME has not completed your medical evaluation report within the required time from the date of your evaluation. You can accept the delay of your evaluation or ask the IMC for a replacement panel and repeat the QME process. To receive a replacement panel, please complete the bottom portion of this letter and return this form to the Industrial Medical Council. If you have any questions, please call the IMC at (1-800) 794-6900 or (415) 737-2767. IF YOU DO NOT RETURN THIS FORM WITHIN 15 DAYS FROM THE ABOVE DATE, YOU WILL NOT BE ASSIGNED A REPLACEMENT PANEL. Name Address Signature Name of QME Doctor RETURN THIS FORM TO: Industrial Medical Council Attn: DWC - Medical Unit P.O. Box 420603 San Francisco, CA 94142 (800) 794-6900 (415) 737-2767 IMC Form 7 (Rev. 2/94) American LegalNet, Inc. www.USCourtForms.com
