State of California Division of Workers' Compensation - Medical Unit Replacement Panel Request-8 Cal. Code of Regulations section 31.5 (Please print or type) Original panel number (Required) Claim number (Required) EAMS number (if a case is filed) Date of Injury(Required): Requesting Party (Required) Applicant's Attorney/Injured Worker Defense Attorney/Claims Administrator Employee first name (Required) Middle Initial Employee last name (Required) Indicate the reason why each QME should be replaced. A list of reasons is included in the instructions to this form. Attach documentation to this form to support the request for a new panel or explain the reason for the request in the space provided below.The failure to adequately document your request may result in your requests being delayed, returned or rejected. 1. QME Name (Required) Reason for Replacement (Required) In Represented cases only: Please check this box if this QME is being replaced because the QME was stricken in the 4062.2(c) process. 2. QME Name Reason for Replacement 3. QME Name In Represented cases only: Please check this box if this QME is being replaced because the QME was stricken in the 4062.2(c) process. Reason for Replacement Use this space to provide additional information about your request; attach additional pages as necessary to explain the issues concerning your replacement request. Please attach additional documentation as necessary to support your request. Requests that are either incomplete, inadequately documented or are otherwise incomprehensible will be returned. Please indicate the new address of the injured worker or the workplace zip code where the panel should be issued in the space provided below. Date of Request: (mm/dd/yyyy) Name of Requestor (Required) Requestor Street Address (Required) Requestor Phone Number: Requestor City (Required) Requestor State Requestor (Required) Zip Code (Required) QME form 31.5-10/2013 Signature of Requestor: 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: , I served this Replacement Panel Request 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: A B 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 C D E Method of Service Person or firm served City Street Address State Zip Code Method of Service Person or firm served City Street Address State Zip Code Method of Service Person or firm served City Street Address State Zip Code Method of Service Person or firm served City Street Address 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 _____________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com QME form 31.5-10/2013 Instructions Replacement panel requests are reviewed and approved based on the reasons set forth in section 31.5 of title 8 of the California Code of Regulation. These reasons are listed below for your use. The form attached to these instructions contains pull down menus that indicate the acceptable reason for a new panel. If you are completing this form by hand, please use the section numbers listed below to indicate the reason or reasons why a QME panel or an individual QME should be replaced. Insert the code section in the "reason for replacement" section, as necessary, provided in the form. For example, if you believe that a QME should be replaced because the QME cannot see the worker in the allotted time period, insert "31.5(a)(2)" in the "reason for replacement" below the name of QME you wish replaced. Attach documentation to support your request. Section number 31.5(a)(1) 31.5(a)(2) 31.5(a)(3) 31.5(a)(4) 31.5(a)(5) 31.5(a)(6) 31.5(a)(7) 31.5(a)(8) Explanation A QME on the panel does not practice in the specialty requested by the party holding the legal right to request the panel. A QME on the panel cannot schedule an examination for the employee within sixty (60) days of the initial request for an appointment, or if the 60 day scheduling limit has been waived pursuant to section 33(e) of title 8 of the California Code of Regulations, the QME cannot schedule the examination within ninety (90) days of the date of the initial request for an appointment. The injured worker has changed his or her residence address since the QME panel was issued and prior to date of the initial evaluation of the injured worker A physician on the QME panel is a member of the same group practice as defined by Labor Code section 139.3 as another QME on the panel. The QME is unavailable pursuant to section 33 of title 8 of the California Code of Regulations (Unavailability of the QME). The evaluator who previously reported in the case is no longer available. A QME named on the panel is currently, or has been, the employee's primary treating physician or secondary physician as described in section 9785 of Title 8 of the California Code of Regulations for the injury currently in dispute . The claims administrator, or if none the employer, and the employee agree in writing, for the employee's convenience only, that a new panel may be issued in the geographic area of the employee's work place and a copy of the employee's agreement is submitted with the panel replacement req