Fillable Qualified Medical Evaluator'S Findings Summary Form (Page 2 of 4) in pdf

Pending or

Yes

Info. Not Sent

17. If the AMA Guides are used, are percentages of impairment stated?

18. Are there any relevant diagnostic test results (x-ray/laboratory)?

19. What are the diagnoses? (List)

_________________________________________________________________________

20. Were medical records reviewed?

21. Were other physicians consulted?

Are there any unresolved disputed issues beyond the scope of your licensure or clinical competence that

22.

should be addressed by an evaluator in a different specialty?

23. If the answer to # 22 is yes, what disputed issue(s)?

_________________________________________________________

24. Based on the answer in # 23, what specialty (or specialties)?___________________________________________

________________________________________________________________________________________________________

QME

22. Signature:___________________________________________________________Date:__________________________

23. Name:_____________________________________________________Specialty:_______________________________

24. Street Address:______________________________________City:___________________________Zip:_____________

25. Phone:_______________________________________ Cal. License No.:_______________________________________

Declaration of Service of Medical - Legal Report (Lab. Code § 4062.3(i))

I, ______________________________________________________________________________________, declare:

(Print Name)

I am over the age of 18 and I am not a party to this case.

My business address is :_________________________________________________________________________________________

On the date shown below, I served this QME Findings Summary Form with the original, or a true and correct copy of the original, comprehensive

medical-legal report, which is attached, on each of the persons or firms named below, by placing it in a sealed envelope, addressed to the person or

firm named below, and by:

depositing the sealed envelope with the U. S. Postal Service with the postage fully prepaid.

placing the sealed envelope for collection and mailing following our ordinary business practices. I

am readily familiar with this business’s practice for collecting and processing correspondence for

mailing. On the same day that correspondence is placed for collection and mailing, it is deposited

in the ordinary course of business with the U. S. Postal Service in a sealed envelope with postage

fully prepaid.

placing the sealed envelope for collection and overnight delivery at an office or a regularly utilized

drop box of the overnight delivery carrier.

placing the sealed envelope for pick up by a professional messenger service for service. (Messenger

must return to you a completed declaration of personal service.)

personally delivering the sealed envelope to the person or firm named below at the address shown

below.

QME Form 111 (rev. February 2009)

Qualified Medical Evaluator'S Findings Summary Form Page 2