Qualified Medical Evaluator Complaint Form Department of Industrial Relations Division of Workers' Compensation - Medical Unit P. O. Box 71010 Oakland, CA 94612 Instructions for Completing this Complaint Form 1. Legibly print or type all information. 2. Provide the name of the Qualified Medical Evaluator and the date of the evaluation. 3. Provide the address where the evaluation was performed. 4. If you are complaining about the contents of the report or the way the evaluation was conducted, please include the medical report of the QME, if available. 5. Please sign and date the complaint form. NOTICE: Except for the name of the physician, the remainder of the information requested is voluntary; however, the failure to provide the requested information may delay or prevent the investigation of your complaint. Please provide as much information as possible in your complaint. The Division of Workers' Compensation will use the information in your complaint in part to determine whether a violation of state law has occurred. If a violation is substantiated, the information may be transmitted to other government agencies. QME Complaint Form rev. 12/08 Page 1 of 3 American LegalNet, Inc. www.FormsWorkFlow.com Qualified Medical Evaluator Complaint Form Department of Industrial Relations Division of Workers' Compensation - Medical Unit P. O. Box 71010 Oakland, CA 94612 (For DWC use only) COMPLAINT AGAINST Physician's First Name Physician's Last Name Address where the Evaluation took place City Phone Number Zip Code Date of Evaluation QME Panel Number Panel Qualified Medical Evaluation Agreed Medical Evaluation COMPLAINANT First Name Last Name Mailing Address City Daytime Phone Number State Fax Number Zip Code E-mail Address If you are making a complaint and you are not the injured worker, please list the name of the injured worker. Name of Injured Worker: INFORMATON ABOUT THE CLAIM If you are the injured worker, please list the name of the insurance company/employer and the name and telephone number of your claims adjuster. Name of Claims Adjuster Phone Number of Claims Adjuster Insurance Company or Employer Claim Number If your complaint involves an examination performed by a Qualified Medical Examiner in a case pending before the Workers' Compensation Appeals Board, please list the case and the case number. If the WCAB has held a hearing or issued any orders about this examination, please attach the minutes of hearing or the Board order to this complaint. Case Name Case Number(s) QME Complaint Form rev. 12/08 American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 3 GIVE US THE DETAILS LOF YOUR COMPLAINT Please list the details of your complaint and attach any documents that you believe would be useful for the investigation. Use as many additional sheets paper as necessary to tell us about your complaint. Date: Signature American LegalNet, Inc. www.FormsWorkFlow.com QME Complaint Form rev. 12/08 Page 3 of 3