Qme Form 106 - Request For Qme Panel Under Labor Code Form
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4State of California
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DIVISION OF WORKERS' COMPENSATION - MEDICAL UNIT
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REQUEST FOR QME PANEL UNDER LABOR CODE § 4062.2
REPRESENTED - for injuries occurring prior to January 1, 2005
(Please print or type)
Date of Injur
Claim Number
Specialty of Treating Physician
:
(Required)
y(Required):
(Required):
Specialty Requested
Opposing Party's Specialty Preference
(Required):
(If known):
Requesting party
(Required: check one box only)
Defense Attorney /Claims Administrator
Applicant's Attorney
(
Reason QME panel is being requested
Required:
check one box only)
§ 4060 (compensability exam)
§ 4061 (permanent disability dispute)
§ 4062 (non medical treatment dispute under 4062)
Employee Information (
Required)
First Name:
Middle Initial:
Last Name:
Mailing Address:
City:
State:
If currently not living in state, enter the California zip code on date of injury:
Zip Code:
If never resided in state, enter the California zip code agreed on for the evaluation:
(
Answer each question below
)
Required
If the employee has seen an A ME/ QME for this injury, provide the
Has the employee ever had an AME/QME exam before?
No
Yes
information below:
If yes, has that claim been settled or resolved?
Yes
No
Name of AME/QME seen:
Is this a dispute about a current need for medical treatment?
Yes
No
Date of Exam:
Is this a dispute over an additional body part ?
Yes
No
Name of the Primary Treating Physician:
Date of Report being objected to:
Describe the nature of the dispute that requires resolution:
Employee's Attorney (
Required)
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
QME Form 106 (rev. 9/2015)
Page 1 of 4
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