STATE OF CALIFORNIA
Division of Workers’ Compensation – Medical Unit
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P.O. Box 71010, Oakland, CA 94612
(510) 286-3700 or (800) 794-6900
QUALIFIED MEDICAL EVALUATOR'S FINDINGS SUMMARY FORM
UNREPRESENTED INJURED EMPLOYEE CASES ONLY
________________________________________________________________________________________________
EMPLOYEE
1. Employee Name (First, Middle, Last)
2. Social Sec. No. (Optional)
3. Date of Injury
.
4
Street Address
City
Zip
5. Phone
________________________________________________________________________________________________________
CLAIMS ADMINISTRATOR (if none, enter Employer information)
.
6
Name
7. Street Address
City
Zip
8. Phone
________________________________________________________________________________________________________
EVENT DATES
9. Date of Appointment Call
10. Initial Examination Date
11. Date of Referral for Medical Testing/Consultation
12a. Date QME Report Served on all Parties
12b. Date(s) of all prior report(s) served by this QME?
________________________________________________________________________________________________________
DISPUTED MEDICAL ISSUES AND CONCLUSIONS
13. The following medical issues will be used to determine the injured employee’s eligibility for workers' compensation benefits.
(
Check the appropriate box)
Pending or
Yes
No
Info. Not Sent
a. Has the condition reached permanent and stationary
status or maximum medical improvement?
b. Is there permanent impairment/disability?
c. Did work cause or contribute to the injury or illness?
d. If permanent disability exists, is
apportionment warranted?
e. Is there a need for current or future medical care?
Yes
No
f. Can this employee now return to his/her usual job?
If yes:
Yes
No,
If YES, Date: ________________
i. Without restrictions
Yes
No,
If YES, Date: ________________
ii. With restrictions
________________________________________________________________________________________________________
(
BASIS FOR CONCLUSIONS
Check the appropriate box)
Pending or
Yes
No
Info. Not Sent
14. Are there subjective complaints?
15. Are there any abnormal physical or psychological
examination findings?
16. Are impairments described and measured using:
(For non-psyche injuries)
the AMA Guides?
(For psyche injuries) the GAF and 2005 PD Schedule?
QME Form 111 (rev. February 2009)