Imc Form 111 - Qualified Or Agreed Medical Evaluator'S Findings Summary Form Page 2
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2Department of Industrial Relations, Industrial Medical Council, PO Box 8888, San Francisco, CA 94128 -(650) 737-2700
Instructions
To the QME or AME: You are required by Labor Code section 4061 to summarize the medical
findings from your comprehensive medical-legal evaluation on the form prescribed by the Industrial
Medical Council (IMC). Please complete the form in its entirety.
Employee Information: Fill in employee's full name, address, telephone number and date of injury
Exam Referral Schedule: complete dates that patient called for an appointment, date of initial
examination, date referred for consultation(s), if any, and date report served on all parties.
Supplying these dates are a legal requirement.
Disputed Medical Issues and Conclusions: Complete this section by checking appropriate box
and stating what page(s) or section of the medical legal report contain the narrative for details. If
diagnostic or laboratory tests have been ordered and the results or a medical records request is
pending, check that box. If you cannot render opinions because of pending information, please
complete and serve the report to comply with the 30 day time requirement and state what issues
could not be evaluated.
Basis for Conclusions- Check appropriate box and give page numbers or section where the
narrative in the full report is found. For diagnoses, in addition to page numbers, please briefly
summarize the diagnoses in lay terms where possible. Also, list name and specialty for other
physicians who provided information used in the medical legal report.
Signature Remember under the Labor Code, all your reports must be signed under the penalty of
perjury.
You are required to serve the medical legal report and this form on the employee, the claims
administrator, (if none, employer) and the Disability Evaluation Unit (DEU) having jurisdiction over
the employee's area of residence.
Authority cited:
Sections 139, 139.2, and 4061 Labor Code.
Reference:
Sections 139.2 and 4061 Labor Code.
IMC Form 111 Rev. 4/14/00
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