Qme Form 105 Request For Qualified Medical Evaluator Panel (Unrepresented Employee)
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State of California, Division of Workers’ Compensation
REQUEST FOR QUALIFIED MEDICAL EVALUATOR PANEL
(Unrepresented Employee)
TO REQUEST A QUALIFIED MEDICAL EVALUATOR (QME) PANEL FOR AN UNREPRESENTED EMPLOYEE:
1. Complete this form (print or type the information). Sign and date at bottom.
2. If the request is made to determine if the injury is work-related, include a copy of the claims administrator’s
notice that the claim was denied, or a copy of the claims administrator’s request for an evaluation.
3. Complete the attached Proof of Service.
4. For Employee: Mail the completed signed form and Proof of Service to:
Division of Workers’ Compensation – Medical Unit
P.O. Box 71010, Oakland, CA 94612
(510) 286-3700 or (800) 794-6900
5. For Employee: Mail or deliver a signed copy of the form and Proof of Service to your Claims Administrator.
6. For Claims Administrator/Defense Attorney: Mail the completed signed form, attach a copy of the written
objection to an opinion of a treating physician, and Proof of Service, to the Medical Unit with a copy served to
the Employee.
Panel Request Information :
Date of Injury: _____________ Claim Number:_________________ Specialty Requested:_____________________
(Select only ONE specialty)
Requesting Party:
Employee
Claims Administrator
Defense Attorney
Reason for QME Panel Request (check one):
To determine if the injury is work-related (attach claims administrator’s notice that claim was denied or a copy of the
claims administrator’s request for an evaluation).
Objection to Primary Treating Physician’s determination regarding temporary disability, permanent disability, or the
need for future medical care.
Work injury claim is accepted for one or more body parts, there is a dispute over additional body parts.
Other (specify non-medical treatment dispute): _______________________________________________________
Employee Information
First Name:__________________________ Middle Initial:_____
Last Name: _________________________________
Street Address or P.O. Box: __________________________________________________________________________
City:_________________________
State __________ Zip Code:_____________________________
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: __________________
Employer/Claims Administrator Information
Employer:_________________________________________ Zip Code of Employer:_______________________
Claims Administrator Company Name:___________________ Adjuster/Contact Name (if known):___________________
Street Address or P.O. Box:____________________________________________________________
City:_________________________ State:_____ Zip Code:___________ Phone No.:__________________________
Requestor Signature:
Date:____________________________________
QME Form 105 (rev. 09/15)
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