Attachment To Qme Form 106 - 2009 printable pdf download

STATE OF CALIFORNIA

DEPARTMENT OF INDUSTRIAL RELATIONS

DIVISION OF WORKERS’ COMPENSATION – MEDICAL UNIT

MAILING ADDRESS:

P. O. Box 71010

Oakland, CA 94612

(510) 286-3700 or (800) 794-6900

HOW TO REQUEST A QUALIFIED MEDICAL EVALUATOR

IN A REPRESENTED CASE

(Attachment to Form 106)

Use QME Form 106 only in cases in which the injured employee is represented by an attorney. To request a panel of

three QMEs in a represented case, the parties first must have attempted to agree on an Agreed Medical Evaluator to

resolve a disputed issue as provided by Labor Code Section 4062.2. Once ten (10) days have passed from the date of the

first written proposal to use an AME that names one or more physicians, either party may request a panel on QME Form

106. Complete form 106, specify the specialty requested, attach a copy of the first written AME proposal, and send your

request by first class U.S. mail to the DWC – Medical Unit address on the bottom of the form. You must serve a copy of

your panel request on the other party. If the panel request form is not fully completed, it will be returned.

Completing the form:

“Request Date”:

Write the date you sign this form.

“Requesting Party”:

Check the box that describes the person or party with the legal right to request a panel

who is signing the form at the bottom.

Answer the questions, about whether any part of the claim has been accepted, whether the claim has been

denied; and about attaching a copy of the earliest written AME offer that identifies a disputed issue and names

one or more physicians to be the AME.

Selecting the reason for requesting a QME panel:

Select “§ 4060 (compensability exam)”

if the claims administrator advises within ninety (90) days of receipt of the

claim form that a QME report is needed to determine whether to accept the claim; or if there is a dispute over the treating

physician’s opinion that the claimed injury was not caused by work. If the claims administrator has accepted any part of

the claim, such as accepting one body part or injury, select a different reason (Lab. Code § 4060(a).) If the ninety (90) day

period has passed since the claim form was received, a request from a claims administrator or employer for a QME panel

for this reason will not be filled until the conditions in section 30(d)(4) of Title 8 of the California Code of Regulations

have been satisfied.

Select “§ 4061 (permanent impairment or disability dispute)”

if there is a dispute about temporary or permanent

impairment or disability, or you disagree over the amount or percentage of permanent impairment or permanent disability.

Select “§ 4062 (injured employee only - medical treatment or UR dispute or other 4062 reason)”

treatment has been denied, delayed or modified by a utilization review physician or the claims administrator; or if there is

a dispute over the amount or frequency or type of treatment that the injured employee needs now or will need in the

future. Select this reason also if the dispute is about ‘permanent and stationary’ status. The claims administrator may not

select this after treatment has been denied, delayed or modified in utilization review.

Select “§ 4062 (claims administrator only – other non-treatment, non-UR reason under § 4062)”

whenever

the claims administrator, or if none the employer, objects to some other medical determination or issue under Labor Code

§ 4062. The requesting claims administrator must state the reason on the line provided. Examples may include medical

determinations on new and further disability, medical eligibility for vocational rehabilitation, the permanent and stationary

date, MPN continuity of care or transfer of care, that a new body part needing treatment is causally connected to the

claimed injury.

Attachment to QME Form 106

Rev. February 2009

Attachment To Qme Form 106 - 2009

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