State of California Department of Industrial Relations Division of Workers' Compensation Request for Factual Correction of an Unrepresented Panel QME Report Person Requesting Correction (Required) Employee Date of Birth (MM/DD/YYYY) (Required) Date of Injury (MM/DD/YYYY) (Required) QME, Case and Report information (Required) QME Name (Please leave blank spaces between numbers, names or words) QME Street Address (Please leave blank spaces between numbers, names or words) QME City State Zip Code Panel Number Employee Information (Required) Employee First Name: MI Employee Last Name: Date Report served (MM/DD/YYYY) Employee Street Address/PO Box (Please leave blank spaces between numbers, names or words) Employee City (Please leave blank spaces between numbers, names or words) State Employee Zip Code Employer and Claims Administrator Information (Required) Employer Name (Please leave blank spaces between numbers, names or words) Claims Administrator Company Name (Please leave blank spaces between numbers, names or words) Claims Administrator Street Address/PO Box (Please leave blank spaces between numbers, names or words) Claims Administrator City State Administrator Zip Code Indicate the factual information that you believe is incorrect. Do not attach any additional medical information to this form. You may attach additional pages to point out the factual issues you believe need correction. Date: (MM/DD/YYYY) QME Form 37 (10/2013) Signature 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 Request for Factual Correction of an Unrepresented Panel QME Report, 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 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 B C D E Method of Service Person or firm served Street Address City State Zip Code Method of Service Person or firm served Street Address City 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 _____________________________________________ QME Form 37 (10/2013) American LegalNet, Inc. www.FormsWorkFlow.com HOW TO REQUEST A FACTUAL CORRECTION OF AN UNREPRESENTED PANEL QME REPORT An unrepresented injured worker or a claims administrator, including the administrator's representative, may request a panel Qualified Medical Evaluator (panel QME) to review a medical evaluation to correct factual errors in the report before the report is rated by the Disability Evaluation Unit (DEU). A request for a factual correction means a change to a statement or assertion of fact contained in the QME evaluation that can be verified from the written records submitted to the panel QME. When and how should the request for factual correction be made? An unrepresented employee or the claims administrator may request the factual correction of a comprehensive medical-legal report within 30 days of the receipt of a comprehensive medical report from a panel QME finding the existence of permanent disability. A request for factual correction must use the form in section 37(f) of title 8 of the California Code of Regulations. When completed, the form must be served on (1) the panel QME who examined the injured worker, (2) the party who did not file the request, and (3) the DEU office where the comprehensive medical-legal report was served. Instructions for completing the factual correction form are discussed in the table below. Field Person requesting correction Instruction Required or not Indicate if you are the injured worker or a claims examiner or their representative. Required Employee Date of Birth Use MM/DD/YYYY for the date. Date of Injury Required Required Insert the date the injury occurred. If this is cumulative trauma injury, insert the last date of exposure of or the last date of work. Use MM/DD/YYYY for the date. This section requests the name and address of the QME who examined the employee as well as the panel number that the QME was chosen from and the date the QME's medical report was filed. QME, case and report information Required Employee information This section requests the name and address of the injured worker who was examined. Required Employer and claims administrator information This section asks for the name of the employer and the name and address of the claims administrator(insurance company or third-party administrator, for example.) Required Indicate the factual Relate the facts you believe the QME has either omitted or gotten wrong in the medical information you believe report. You may add as many additional pages as necessary to point out the corrections or is incorrect the factual additions to the report that should be made. However, you may not attach any Required additional medical information to this form for the QME's consideration. Date, name of the Insert the date the form is completed. Use the MM/MM/YYYY format. Print the name of requestor and signature the person requesting the QME panel. The requestor must sign the request where indicated. Required Declaration of Service Attached to the form