Attachment To Qme Form 106 - 2009 (Page 2 of 3) in pdf

If the injured employee is covered for medical treatment by an MPN and the parties disagree over the MPN physician’s

diagnosis or treatment, you do not need a QME. The parties must follow the MPN second opinion process set out in

Labor Code section 4614.3 and section 9767.7 of Title 8 of the California Code of Regulations.

Select “§§ 4061 and 4062”

if currently there are disputes about both permanent disability and medical determinations.

Selecting the medical specialty:

Enter the 3 letter code from the reverse side of QME Form 106 for the medical specialty requested. If known, also state

the medical specialty of the treating physician and the specialty preferred by the opposing party. If you are requesting a

specialty that is different than the medical specialty of the primary treating physician, it is strongly recommended that you

submit additional, relevant medical documentation in support of the requested specialty and an explanation of the reasons

you believe the specialty being selected is more appropriate for review by the Medical Director of DWC. Such additional

medical documentation may include, but is not limited to, copies of the most recent primary treating physician’s progress

report (DWC Form PR-2), the Doctor’s First Report of Occupational Injury or Illness (Form DLSR 5021), a consulting

physician’s report, etc. . It is not necessary to send copies of all medical records in the case. (See sections 31.1 and 31.5

of Title 8 of the California Code of Regulations.)

The DWC-MU uses a random selection program to assign three QMEs to the panel. If there are too few QMEs of the

specialty requested in the geographic area of the injured worker’s residence, the system will pick QMEs from other

geographic areas and the employer is responsible for paying for necessary travel costs incurred. The non-requesting party

will receive a copy of the panel letter when it is issued. If the Medical Unit does not issue a panel within thirty (30)

calendar days of receiving the request in a represented case, either party may seek an order from a Workers’

Compensation Administrative Law Judge to obtain a QME panel.

The AME or QME selection process in represented cases:

Upon receipt of the QME panel list, the parties in a represented case are required to confer and attempt to agree on an

Agreed Panel QME from the panel list provided. (See, Labor Code section 4062.2(c).) If the parties have not agreed on

an Agreed Panel QME by the 10th day after the panel is issued, each party may then strike one name from the panel. The

remaining QME shall serve as the medical evaluator. If a represented party fails to exercise the right to strike a name from

the panel within three business days of gaining the right to do so, the other party may select any QME who remains on the

panel to serve as the medical evaluator. (Labor Code §4062.2(c)).

Requests returned for additional information and replacement evaluators:

If a QME panel was previously issued for this injured worker and there is insufficient information on the form 106 to

process the request, the request will be returned by the Medical Unit with a request for necessary information. The time

periods for selecting an Agreed Panel QME and for striking QME names are tolled during this period. (See, 8 Cal. Code

Regs. §§ 30(c), 31.5)

Scheduling the evaluation appointment:

The represented employee is responsible for arranging the appointment for the examination. Upon his or her failure to

inform the employer/insurer of the appointment within 10 business days after the medical evaluator has been selected, the

employer/insurer may arrange the appointment and notify the employee of the arrangements.

How long will it take to have the examination and to get the QME’s report?

If the QME selected is unable to schedule the exam within 60 calendar days of the initial call, the party with the legal right

to schedule may either waive the 60 day limit, as long as an appointment within 90 days of the initial scheduling call is

Attachment to QME Form 106

Rev. February 2009

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Attachment To Qme Form 106 - 2009 Page 2