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 Arnold Schwarzenegger, Governor IMPORTANT: RETURN TO THE IMC WITHIN 15 DAYS Date: TO: EMPLOYEE'S NAME: Claim Number: Panel Number: NOTICE OF LATE QME REPORT - NO EXTENSION REQUESTED It has come to our attention that your QME doctor 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 report or ask the IMC for a replacement panel and repeat the QME process. You are required to make a decision, check, sign and return this form using the postage prepaid return envelope within 15 days. This time period may be extended upon a showing of good cause to the Medical Director. ( ) Check here if you give up your right to a new QME panel at this time. You have up to the date the QME serves the report to call and request a new panel. ( ) Check here if you wish to have a new QME panel. Signature: Date: If you are represented, please consult your attorney. If you have any questions, please call (650) 737-2767/800-794-6900 or write to: Industrial Medical Council Attn: DWC - Medical Unit P.O. Box 420603 San Francisco, CA 94142 cc: Claims Administrator QME Authority cited: Reference: Sections 139 and 139.2, Labor Code Sections 139.2, 4060, 4061, 4062 and 4062.5, Labor Code IMC Form 116 Rev. 3/01/00 IMC Regs-Forms American LegalNet, Inc. www.USCourtForms.com