State of California Division of Workers' Compensation-Medical Unit QME/AME Report Time Frame Extension Request File this form with the Division of Workers' Compensation-Medical Unit 5 days before your report is due to be served on the parties and send a copy of this form to the employee and claims administrator.The QME may not be entitled to payment for evaluations which are not submitted in a timely manner. (Labor Code § 4062.5.) Review 8 Cal. Code Regs. § 38(i) regarding extension of time for supplemental report. If you need further information, please call us at (510) 286-3700 or 1-800-794-6900. Legibly Print or Type the information requested in this form.You may fax this request, along with the completed proof of service, to (510) 622-3467. Completion of this section is required Date of Physical Evaluation (Required): Date Report will be served (Required): Request for 30 day extension. Indicate the reason for the request below : Lab or test results not received. Type of Test: Report of consulting physician not received. Specialist Type: Request for 15 day extension. Indicate the reason for the request below: Medical emergency of the evaluator or evaluator family member. Death in evaluator's family. Natural disaster/other community catastrophe interrupted office. Completion of this section is required Employee's Name Claims Administrator QME Name Date signed QME Signature Claim No. Date of Injury Panel No. CA Lic. No. CA QME Street Address QME City QME State QME Zip Code Telephone Number Fax Number FOR DWC USE ONLY ( ) Extension approved ( ) Extension denied and notice mailed to evaluator and parties Date American LegalNet, Inc. www.FormsWorkFlow.com Medical Director: QME Form 112 (rev.10/2013) 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 QME/AME Report Time Frame Extension Request with the original, or a true and correct copy, 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 Method of Service Person or firm served State Zip Code 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 112 (rev.10/2013) American LegalNet, Inc. www.FormsWorkFlow.com