Qualified Medical Evaluator'S Findings Summary Form Page 3
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4Means of service:
Date:
Addressee and Address:
(For each addressee,
Enter A – E as appropriate)
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When report addresses PD:
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Disability Evaluation Unit, DWC,__________________________________________
I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
Date Signed: ____________________________________
___________________________________________________
_______________________________________________
(Signature of Declarant)
(Print Name)
INSTRUCTIONS FOR QME FORM 111
USE THIS FORM ONLY WHEN THE INJURED EMPLOYEE IS UNREPRESENTED
To the QME: You are required by Labor Code section 4062.3(i) to summarize the medical findings from your
comprehensive medical-legal evaluation on the form prescribed by the Administrative Director. Please complete
the form in its entirety.
Employee Information: Fill in the employee's full name, address, telephone number and date of injury.
Event Dates: Complete dates that patient called for an appointment, date of initial examination, date referred for
consultation(s), if any, and date(s) report(s) served on all parties. Supplying these dates is a legal requirement.
Disputed Medical Issues and Conclusions: Complete this section by checking appropriate box and stating what
page(s) or section of the medical legal report contain the narrative for details. If diagnostic or laboratory tests
have been ordered and the results or a medical records request is pending, check that box. If you cannot render
opinions because of pending information, please complete and serve the report to comply with the 30-day time
requirement and state what issues could not be evaluated.
Basis for Conclusions: Check appropriate box for each question on form. For diagnoses, please briefly
summarize the diagnoses in lay terms where possible, except when you deem that not advisable in disputed
claims involving injury to the psyche. Also, list the name and specialty for other physicians who provided
information used in the medical legal report.
Need for Additional Evaluation in Another Specialty: Labor Code section 4062.3 directs each evaluator to
address all contested medical issues arising from all injuries reported on one or more claim forms prior to the
evaluator’s initial evaluation. Each evaluator is expected to address permanent impairment consistent with the
AMA guides for the evaluator’s specialty, or for disputed injuries to the psyche consistent with the global
assessment of functioning (GAF) as directed in the 2005 Permanent Disability Schedule adopted by the
Administrative Director effective 1/1/2005. In the event there are contested medical issues outside of the scope
QME Form 111 (rev. February 2009)
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Parent category: Legal