State of California DIVISION OF WORKERS' COMPENSATION - MEDICAL UNIT REQUEST FOR QME PANEL UNDER LABOR CODE § 4062.2 REPRESENTED - for injuries occurring prior to January 1, 2005 Date of Injury(Required): (Please print or type) Specialty of Treating Physician (Required): Claim Number (Required): Specialty Requested (Required): Opposing Party's Specialty Preference (If known): Requesting party (Required: check one box only) Applicant's Attorney Defense Attorney /Claims Administrator § 4062 (non medical treatment dispute under 4062) Reason QME panel is being requested (Required: check one box only) § 4060 (compensability exam) § 4061 (permanent disability dispute) Employee Information (Required) First Name: Mailing Address: Zip Code: Middle Initial: City: Last Name: State: If currently not living in state, enter the California zip code on date of injury: If never resided in state, enter the California zip code agreed on for the evaluation: Answer each question below (Required) Has the employee ever had an AME/QME exam before? If yes, has that claim been settled or resolved? Is this a dispute about a current need for medical treatment? Is this a dispute over an additional body part ? Name of the Primary Treating Physician: Describe the nature of the dispute that requires resolution: Yes Yes Yes Yes No No No No If the employee has seen an A ME/ QME for this injury, provide the information below: Name of AME/QME seen: Date of Exam: Date of Report being objected to: Employee's Attorney (Required) First Name Law Firm Name Address/PO Box (Please leave blank spaces between numbers, names or words) City QME Form 106 (rev. 9/2015) Last Name State Zip Code Phone Number American LegalNet, Inc. www.FormsWorkFlow.com Page 1 of 4 (Continue form on next page) Claim Number: Employer and Claims Administrator Information Employer: Claims Administrator Company Name: Claims Adjustor Name: Street Address or P.O. Box: City: State: Zip Code: Phone Number: Defendant's Attorney First Name Law Firm Name Last Name Address/PO Box (Please leave blank spaces between numbers, names or words) City State Zip Code Phone Number Date: Print Name of Requestor Signature of Requestor Note: The party submitting this form must attach a copy of the written objection to an opinion of a treating physician identifying an issue in dispute. The completed form must be mailed to: Division of Workers' Compensation-Medical Unit P Box 71010, Oakland, CA 94612 .O. (510) 286-3700 or (800) 794-6900 QME Form 106 (rev. 9/15) Page 2 of 4 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 QME 106 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 _____________________________________________ QME Form 106 (rev. 9/2015) American LegalNet, Inc. www.FormsWorkFlow.com For Use with the QME Panel Request Form 106 MD/DO SPECIALTY CODES MAA MAI MDE MEM MFP MPM MHH MMV MME MMG MMH MMI MMO MMN MMP MMR MNB MPN MNS MOG MOQ MPO MOP MOS MTO MPA MHA MPR MPS MPD MSY MSG MTS MTT MUU Anesthesiology Allergy and Immunology Dermatology Emergency Medicine Family Practice General Preventive Medicine Hand Internal Medicine - Cardiovascular Disease Internal Medicine - Endocrinology Diabetes and Metabolism Internal Medicine - Gastroenterology Internal Medicine - Hematology Internal Medicine - Infectious Disease Internal Medicine - Medical Oncology Internal Medicine - Nephrology Internal Medicine - Pulmonary Disease Internal Medicine - Rheumatology Spine Neurology Neurological Surgery (other than Spine) Obstetrics and Gynecology Medicine Otherwise Qualified Occupational Medicine Ophthalmology Orthopaedic Surgery (other than Spine or Hand) Otolaryngology Pain Medicine Pathology Physical Medicine & Rehabilitation Plastic Surgery (other than Hand) Psychiatry (other than Pain Medicine) Surgery (other than Spine or Hand) Surgery - General Vascular Thoracic Surgery Toxicology Urology NON-MD/DO SPECIALTY CODES ACA DCH DEN OPT POD PSY Acupuncture Chiropractic Dentistry Optometry Podiatry Psychology MMM Internal Medicine Do not file this page with your form! QME Form 106 (rev. 9/2015) American LegalNet, Inc. www.FormsWorkFlow.com