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

Qualified Medical Evaluator'S Findings Summary Form Page 4

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of your licensure or clinical competence that require evaluation by a physician in a different specialty, complete

the information required in questions 22 through 24, and serve a copy of your report on the Medical Unit of

DWC.

QME Signature: Remember under the Labor Code, all your reports must be signed under the penalty of perjury.

You are required to serve the medical legal report and this form on the employee (unless the claim involves a

disputed injury to the psyche and section 36.5 of Title 8 of the California Code of Regulations applies and

provides for a different method of service), the claims administrator (if none, the employer) and whenever the

report finds permanent impairment and permanent disability, on the Disability Evaluation Unit (DEU) having

jurisdiction over the employee's area of residence.

Declaration of Service of Medical – Legal reports: Labor Code sections 139.2(j)(1)(A) and 4062.3 (i) and

section 38 of Title 8 of the California Code of Regulations require the QME to serve the medical-legal report and

this form on the claims administrator, or if none the employer, and the injured worker (except when section 36.5

of Title 8 of the California Code of Regulations applies) within 30 days from the commencement of the

examination, unless certain conditions are met. Please complete the proof of service to show the date the report

was served on the parties and the Disability Evaluation Unit.

QME Form 111 (rev. February 2009)

Qualified Medical Evaluator'S Findings Summary Form Page 4

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