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Replacement Panel Request Form. This is a California form and can be use in General Workers Comp.
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Tags: Replacement Panel Request, QME 31.5 Opt., California Workers Comp, General
State of California
DIVISION OF WORKERS’ COMPENSATION – MEDICAL UNIT
REPLACEMENT PANEL REQUEST
TITLE 8, CALIFORNIA CODE OF REGULATIONS § 31.5
(Please print or type)
If anything has changed including parties, addresses, and represented status,
Please attach the information on a separate sheet of paper
Date of Request: (Required)
Original Panel No.: (Required)
__________________
___________________________
Requesting Party: (Check one box only)
Applicant’s Attorney/Injured Worker
Defense Attorney/Claims Administrator
Claim No.: (Required) ____________________
Injured Worker: (Required)
________________________
First Name
___________________________
Last Name
Name of QME(s) to replace:
1. ____________________________
2. ____________________________
Reason #: _____
Reason #: _____
3.
Entire Panel List
Reason #: _____
Reason for Replacement (all references are to Title 8, CCR 31.5 unless otherwise noted):
You must attach relevant supporting documentation.
1.
2.
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16.
17.
QME on the panel issued does not practice in the specialty requested. (a) (1)
A QME on the panel issued cannot schedule an appointment within 60 – 90 days. (a)(2) (Please indicate date
of initial request for an appointment)
The injured worker has changed his or her residence address. (a)(3)
New Address: __________________________________________________________
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)
The QME is unavailable pursuant to § 33 (Unavailability of the QME). (a)(5) and § 33
The evaluator who previously reported in the case is no longer available. (a)(6)
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)
Parties agree to a new panel in the region of the employee’s workplace. (a)(8) (Please attach agreement)
Workplace Zip Code: ________
Good cause for a different specialty due to medical nature of injury. (a)(9) (Attach medical documentation)
Inappropriate specialty for disputed medical issues. (a)(10) (Attach medical documentation)
No appointment notification (Form 110). (a) (11) and § 34 (Attach statement explaining how and when you
became aware of the violation)
Late report. (a) (12) and § 38 (Attach evidence of lateness)
Disqualifying conflict of interest (a) (13) and § 41.5 (Attach evidence of conflict)
AD order for an additional QME evaluation. (a)(14) and § 10164 (c) (Attach AD order)
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)
No QME used from a panel issued over 24 months ago. (a) (16)
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 and Phone Number (Print)
Requestor’s Signature
_______________________________________
____________________________________
QME Form 31.5 Opt.
Rev. May 2010
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