State of California DIVISION OF WORKERS’ COMPENSATION – MEDICAL UNIT REPLACEMENT PANEL REQUEST TITLE 8, CALIFORNIA CODE OF REGULATIONS § 31.5 (Please print or type) Request Date: Original Panel Number (Required): ____________ _____________________________ Requesting Party (Check one box only): Applicant’s Attorney/Injured Worker Defense Attorney/Claims Administrator 1. ____________________________________ Reason # ________ 2. ____________________________________ Name of QME(s) to replace: Reason # ________ Reason # ________ Entire Panel List Reason for Replacement (all references are to Title 8, CCR 31.5 unless otherwise noted): You must attach relevant supporting documentation. 1. QME on the panel issued does not practice in the specialty requested. (a) (1) 2. A QME on the panel issued cannot schedule an appointment within 60 – 90 days. (a)(2) 3. The injured worker has changed his or her residence address. (a)(3) New Address: __________________________ 4. A physician on the QME panel is a member of the same group practice as defined by Labor Code § 139.3 as another QME on the panel. (a)(4) (Please attach evidence of form of business entity of group practice) 5. The QME is unavailable pursuant to § 33 (Unavailability of the QME). (a)(5) and § 33 6. The evaluator who previously reported in the case is no longer available. (a)(6) 7. A QME named on the panel is currently, or has been, the employee’s primary treating physician or secondary physician for the injury currently in dispute. (a)(7) 8. Parties agree to a new panel in the region of the employee’s workplace. (a)(8) (Please attach agreement) Workplace Zip Code: __________________________ 9. Good cause for a different specialty due to medical nature of injury (a)(9). (Attach medical documentation) 10. Inappropriate specialty for disputed medical issues. (a)(10) (Attach medical documentation) 11. No appointment notification (Form 110). (a) (11) and § 34 (Attach statement explaining how and when you became aware of the violation) 12. Late report. (a) (12) and § 38 (Attach evidence of lateness) 13. Disqualifying conflict of interest (a) (13) and § 41.5 (Attach evidence of conflict) 14. AD order for an additional QME evaluation. (a)(14) and § 10164 (c) (Attach AD order) 15. Selected QME fails to provide either a complete medical evaluation or a written statement explaining why the evaluator feels he or she is not medically qualified to address disputed issues. (a)(15) 16. No QME used from a panel issued over 24 months ago. (a) (16) 17. Represented parties have each struck a QME from the panel and the last QME may be replaced based on any of the reasons above (c) Name of Requestor (Print) Requestor’s Signature _______________________________________ ____________________________________________ QME form 31.5 Opt. Rev. May 2010 American LegalNet, Inc. www.FormsWorkFlow.com