Please complete this form in its entirety. The Administrative Director requires that you serve this appointment notification form on the employee and the claims administrator, or, if none the employer, and their attorneys in a represented case, if known, within five (5) business days after having scheduled the injured worker to be seen for a QME comprehensive medical-legal evaluation. You may not cancel the appointment less than six (6) calendar days prior to the appointment date, except for good cause (See, 8 Cal. Code Regs. 24734). If you reschedule an appointment, review regulation 34 and the ethical rules in regulation 41 (See, 8 Cal Code Regs. 247247 34, 41(a) (7) and (a) (8)). State of California Division of Workers' Compensation-Medical Unit QME Appointment Notification Form Employee Information Employee Name Employee Street Address Employee City State Zip Code Phone Number Date of Injury Claim or Case NumberEmployer Information Zip Code State Employer City Employer Street Address Employer Name Claims Administrator Information (Completion of this section is required) Zip Code State Claims Administrator City Claims Administrator Street Address Claims Administrator Name (Insert the name of the person handling the claim) Claims Administrator Company (Insert the name of the company handling the claim) Date of appointment call:Appointment Information (Completion of this section is required)Date of Appointment: Examination address Time of appointment: If an interpreter is required, indicate language: QME Name: Zip Code QME City QME Street AddressDate Signed: Signature of the QME: Is a certified interpreter required? Yes NoPage 1 of 2 Examination City: Zip Code Phone NumberRecords should be sent to the following address: Zip Code City: Street address or P.O. Box State American LegalNet, Inc. www.FormsWorkFlow.com 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: On , I served this QME Appointment Notification Form, the original, or a true and correct copy of the original, 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:Adepositing the sealed envelope with the U. S. Postal Service with the postage fully prepaid.Bplacing the sealed envelope for collection and mailing following our ordinary business practices. I am readily familiar with this business222s 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.Cplacing the sealed envelope for collection and overnight delivery at an office or a regularly utilized drop box of the overnight delivery carrier. Dplacing the sealed envelope for pick up by a professional messenger service for service. (Messenger must return to you a completed declaration of personal service.)Epersonally delivering the sealed envelope to the person or firm named below at the address shown below. Person or firm served Zip Code State City Street Address Method of Service Street Address Zip Code State City Person or firm served Method of Service Street Address Zip Code State City Person or firm served Method of Service City State Zip Code: Street Address Person or firm served Method of ServiceI declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.Signature Type or print name , California. at Date:QME Form 110 (rev. 10/2013) American LegalNet, Inc. www.FormsWorkFlow.com