Qme Form 106 - Medical Unit Request For Qme Panel - California Division Of Workers' Compensation

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State of California
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DIVISION OF WORKERS' COMPENSATION - MEDICAL UNIT
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REQUEST FOR QME PANEL UNDER LABOR CODE § 4062.2
REPRESENTED
(Please print or type)
Claim Number (Required):
Request date (Required):
Date of Injury (Required):
Specialty Requested
(3 letter code required):
Requesting party
(Check one box only)
Specialty of treating physician:
Opposing party's specialty preference:
Applicant's Attorney(or injured employee)
Defense Attorney /Claims Administrator
(
Reason QME panel is being requested
:
Read attachment, `How to Request a QME')
(Check one box only)
§ 4060 (compensability exam)
§ 4061 (permanent impairment or disability dispute)
§ 4062 Injured employee only (medical treatment determination, UR dispute or other 4062 reason )
§ 4062 Claims administrator only (non treatment medical determination or non-UR reason under 4062)
§§ 4061 and 4062 dispute (medical treatment and permanent impairment or disability dispute)
If the claims administrator is requesting a 4062 panel explain the reason for the request below:
You must attach a copy of your written proposal identifying a disputed issue and naming one or more physicians to be an
AME.
Answer each question below:
Yes
No
Yes
No
Has this claim been denied?
Has any body part in this claim been accepted?
If yes, indicate the date of the denial
Continuity or Transfer of Care
Does dispute involve an MPN :
Permanent Disability, Future Medical, UR decision
Diagnosis/Treatment ?
Employee Information
First Name:
Middle Initial:
Last Name:
Street Address :
City:
State:
Zip Code:
Daytime Phone No:
If currently living outside of state, enter the California city and zip code on date of injury:
If never resided in state, enter the California city and zip code for evaluation:
Employee's Attorney
Firm Number
First Name
Last Name
Law Firm Name
Address/PO Box (Please leave blank spaces between numbers, names or words)
City
Phone No
State
Zip Code
Page 1 of 3
(Continue form on next page)
QME Form 106 (rev. Feb 2009)

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