Qme Form 106 - Medical Unit Request For Qme Panel - California Division Of Workers' Compensation Page 2

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Claim Number:
Employer and Claims Administrator Information
Employer:
Claims Administrator Name:
Adjustor name:
Street Address or P.O. Box:
City:
State:
Zip Code:
Phone Number:
Defendant's Attorney
Firm Number
First Name
Last Name
Law Firm Name
Address/PO Box (Please leave blank spaces between numbers, names or words)
City
State
Zip Code
Phone Number
Prior QME Panel Information
(Answer all that apply)
Has the employee ever received a QME panel before?
Yes
No
Unknown
Yes
No
Unknown
If yes, did the employee ever see any QME from that panel?
Yes
No
Unknown
If yes, has that claim been settled or resolved?
If yes, name of QME seen:
Specialty:
Date of Injury:
Body parts:
Date of Exam:
Is that QME available now:
Panel Number
Yes
No
Unknown
(If known):
The completed form must be mailed to:
Division of Workers' Compensation-Medical Unit
P.O. Box 71010, Oakland, Ca 94612
(510) 286-3700 or (800) 794-6900
Date:
Signature
Print Name of Requestor:
Note: The party submitting this form must attach a copy of the written proposal identifying a disputed issue and
naming one or more physicians to be a AME.
Page 2 of 3
QME Form 106 (rev. Feb 2009)

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