State of California Division of Workers' Compensation Medical Unit P.O. Box 71010 Oakland, CA 94612 QME Notice of Unavailability Form must be filed 30 days prior to date of unavailability QME first name (Required) (Print or type): QME last name (Required) (Print or type): Complete both pages of this application to request unavailability. It is not an acceptable reason to request unavailability that a QME does not intend to perform evaluations for unrepresented workers. A QME who is unavailable may not schedule or perform QME evaluation examinations (initial or follow up) until the QME returns to active status. A QME may complete reports for evaluation exams performed before becoming unavailable or supplemental reports. A QME who is unavailable for more than 90 calendar days during the calendar year without good cause may be denied reappointment. If this form is being filed less than 30 days before the QME is to become unavailable, attach a separate explanation of good cause for approving the late application. Check the appropriate box to indicate that you will be unavailable for panel assignments for a period of 14 days to 90 days. Completion of this section is required.(Choose only one) I will be unavailable for all qualified medical evaluation panel assignments from to (MM/DD/YYYY) (MM/DD/YYYY) I will be unavailable only at the QME office location (s) listed below for all qualified medical evaluation panel assignments from to (MM/DD/YYYY) (MM/DD/YYYY) Street Address City Street Address City Street Address City Street Address City Street Address City QME signature Calif. License number Zip Code Zip Code Zip Code Zip Code Zip Code Street Address City Street Address City Street Address City Street Address City Street Address City Date Zip Code Zip Code Zip Code Zip Code Zip Code QME Form 109 (rev. 9/2015) Page 1 of 2 Section 33(c) of title 8 of the California Code of Regulations requires a QME to list all of the comprehensive medical/legal evaluation examinations already scheduled during the time requested for unavailable status at the time the request is filed with the medical unit. (Completion of this section is required) Date of the request Appointment date (MM/DD/YYYY) Calif. License number Injured Worker Name I have no examinations scheduled during the period I have requested unavailability. Panel number, if applicable Appointment Type Exam Status Appointment date (MM/DD/YYYY) Injured Worker Name Panel number, if applicable Appointment Type Exam Status Appointment date (MM/DD/YYYY) Injured Worker Name Panel number, if applicable Appointment Type Exam Status Appointment date (MM/DD/YYYY) Injured Worker Name Panel number, if applicable Appointment Type Exam Status Appointment date (MM/DD/YYYY) Injured Worker Name Panel number, if applicable Appointment Type Exam Status Appointment date (MM/DD/YYYY) Injured Worker Name Panel number, if applicable Appointment Type Exam Status Appointment date (MM/DD/YYYY) Injured Worker Name Panel number, if applicable Appointment Type Exam Status Appointment date (MM/DD/YYYY) Injured Worker Name Panel number, if applicable Appointment Type Exam Status Appointment date (MM/DD/YYYY) Injured Worker Name Panel number, if applicable Appointment Type Exam Status Appointment date (MM/DD/YYYY) Injured Worker Name Panel number, if applicable Appointment Type Exam Status Appointment date (MM/DD/YYYY) Injured Worker Name Panel number, if applicable Appointment Type Exam Status Appointment date (MM/DD/YYYY) Injured Worker Name Panel number, if applicable Appointment Type Exam Status Appointment date (MM/DD/YYYY) Injured Worker Name Panel number, if applicable Appointment Type Exam Status Appointment date (MM/DD/YYYY) Injured Worker Name Panel number, if applicable Appointment Type Exam Status QME Form 109 (rev. 9/2015) Page 2 of 2