Request For QME Panel
Request For QME Panel Form. This is a California form and can be use in General Workers Comp.
Tags: Request For QME Panel, QME 106, California Workers Comp, General
State of California DIVISION OF WORKERS' COMPENSATION - MEDICAL UNIT REQUEST FOR QME PANEL UNDER LABOR CODE § 4062.2 REPRESENTED (Please print or type) Request date (Required): Date of Injury (Required): Specialty of treating physician: Specialty Requested (3 letter code required): Claim Number (Required): Requesting party (Check one box only) Applicant's Attorney(or injured employee) Opposing party's specialty preference: Defense Attorney /Claims Administrator Reason QME panel is being requested (Read attachment, `How to Request a QME') (Check one box only): § 4060 (compensability exam) § 4061 (permanent impairment or disability dispute) § 4062 Injured employee only (medical treatment determination, UR dispute or other 4062 reason ) § 4062 Claims administrator only (non treatment medical determination or non-UR reason under 4062) §§ 4061 and 4062 dispute (medical treatment and permanent impairment or disability dispute) If the claims administrator is requesting a 4062 panel explain the reason for the request below: You must attach a copy of your written proposal identifying a disputed issue and naming one or more physicians to be an AME. Answer each question below: Has this claim been denied? Yes No Has any body part in this claim been accepted? Continuity or Transfer of Care Yes Permanent Disability, Future Medical, UR decision No If yes, indicate the date of the denial Does dispute involve an MPN : Diagnosis/Treatment ? Employee Information First Name: Middle Initial: Last Name: Street Address : City: State: Zip Code: Daytime Phone No: If currently living outside of state, enter the California city and zip code on date of injury: If never resided in state, enter the California city and zip code for evaluation: Employee's Attorney First Name Firm Number Last Name Law Firm Name Address/PO Box (Please leave blank spaces between numbers, names or words) City QME Form 106 (rev. Feb 2009) State Zip Code Page 1 of 3 Phone No (Continue form on next page) American LegalNet, Inc. www.FormsWorkflow.com Claim Number: Employer and Claims Administrator Information Employer: Claims Administrator Name: Adjustor name: Street Address or P.O. Box: City: State: Zip Code: Phone Number: Defendant's Attorney Firm Number Last Name First Name Law Firm Name Address/PO Box (Please leave blank spaces between numbers, names or words) City State Zip Code Phone Number Prior QME Panel Information (Answer all that apply) Has the employee ever received a QME panel before? Yes No Unknown If yes, did the employee ever see any QME from that panel? Yes No Unknown If yes, has that claim been settled or resolved? Yes No Unknown If yes, name of QME seen: Date of Injury: Panel Number (If known): Specialty: Body parts: Date of Exam: Is that QME available now: Yes No Unknown The completed form must be mailed to: Division of Workers' Compensation-Medical Unit P.O. Box 71010, Oakland, Ca 94612 (510) 286-3700 or (800) 794-6900 Date: Signature Print Name of Requestor: Note: The party submitting this form must attach a copy of the written proposal identifying a disputed issue and naming one or more physicians to be a AME. QME Form 106 (rev. Feb 2009) Page 2 of 3 American LegalNet, Inc. www.FormsWorkflow.com For Use with the QME Panel Request Form 106 MD/DO SPECIALTY CODES NON -MD/DO SPECIALTY CODES MAI MDE MEM MFP MPM MHH MMM MM V MME ACA DCH DEN OPT POD PSY PSN MMG MMH MMI MMN MMP MMR MNB MPN MNS MOG MPO MMO MOP MOS MTO MPA MHA MPR MPS MPD MSY MSG MTS MTT MUU Allergy and Immunology Dermatology Emergency Medicine Family Practice General Preventive Medicine Hand Internal Medicine Internal Medicine - Cardiovascular Disease Internal Medicine – Endocrinology Diabetes and Metabolism Internal Medicine - Gastroenterology Internal Medicine - Hematology Internal Medicine - Infectious Disease Internal Medicine - Nephrology Internal Medicine - Pulmonary Disease Internal Medicine - Rheumatology Spine Neurology Neurological Surgery (other than Spine) Obstetrics and Gynecology Occupational Medicine Oncology – Orthopaedic Surgery Internal , Medicine or Radiology 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 QME Form 106 (rev. Feb 2009) Page 3 of 3 Acupuncture Chiropractic Dentistry Optometry Podiatry Psychology Psychology - Clinical Neuropsychology American LegalNet, Inc. www.FormsWorkflow.com