Arnold Schwarzenegger, Governor STATE OF CALIFORNIA DEPARTMENT OF INDUSTRIAL RELATIONS INDUSTRIAL MEDICAL COUNCIL DWC - Medical Unit P.O. Box 420603 San Francisco, CA 94142 Tel. No.: (650) 737-2700 or 1-(800) 794-6900 Fax No.: (650) 737-2711 IMPORTANT: RETURN TO THE IMC WITHIN 15 DAYS. Date: TO: EMPLOYEE'S NAME Claim Number: Panel Number: TIME EXTENSION APPROVAL Your QME/AME doctor has asked for an extension of the time in which he/she is required to complete your medical evaluation. We are allowing the doctor extra time to do so. If you are unrepresented and the report is not completed by , you may either: (1) (2) accept the report when it is completed or ask for a replacement panel and repeat the QME process You are required to make a decision, check, sign and return this form using the postage prepaid return envelope within 15 days. ( ) check here if you give up your right to a new QME panel at this time. You have up to the date the QME serves the report to call and request a new panel. ( ) check here if you wish to have a new QME panel sent if the report is not completed by the above date. Signature Date If you are represented, please consult your attorney. If you have any questions, please call (650) 737-2700/800-794-6900 or write to: Industrial Medical Council Attn: DWC - Medical Unit P.O. Box 420603 San Francisco, CA 94142 IMC FORM 113 Rev. 3/01/00 Authority cited: Reference: Sections 139 and 139.2, Labor Code Sections 139.2, 4060, 4061, 4062 and 4062.5, Labor Code IMC Regs-Forms American LegalNet, Inc. www.USCourtForms.com