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State of California DIVISION OF WORKERS' COMPENSATION MEDICAL UNIT REQUEST SOMME Panels UNDER LABOR CODE 4062.1 UNREPRESENTED (Please Complete Form/Type or Print) Request Date: The Party Making the

How to fill out request for qme panel

To fill out a request for a Qualified Medical Evaluator (QME) panel, follow these steps:

1. Gather the necessary information: Collect all relevant medical documentation and records related to the injury or condition for which you are seeking a QME panel.
2. Contact your claims administrator: Reach out to your claims administrator, such as your employer's workers' compensation insurance company, to request the QME panel. They will provide you with the appropriate forms and instructions.
3. Complete the required forms: Fill out the forms provided by your claims administrator accurately and completely. These forms may include your personal information, details about the injury or condition, and specific questions about the type of QME specialist required.
4. Submit the request: Once the forms are filled out, submit them to your claims administrator. Follow their guidelines for submission, which may include mailing the forms or submitting them electronically.
5. Await the QME panel: After submitting the request, the claims administrator will review the information and assign a QME panel. This panel is a list of three QME specialists who are qualified to evaluate your medical condition or injury.
6. Select a QME: From the provided panel, you can choose one QME specialist whose expertise matches your needs. Contact their office to make an appointment for an evaluation.

Who needs a request for a QME panel?

1. Individuals who have sustained a work-related injury or have an active workers' compensation claim.
2. Employees seeking an evaluation from a qualified medical professional to determine the extent of their injury, disability, or need for treatment.
3. Employers or insurance companies responsible for providing approved medical treatment to injured employees in compliance with workers' compensation laws and regulations.

For pdfFiller’s FAQs

What is request for qme panel?

A request for a Qualified Medical Evaluator (QME) panel is a formal document submitted to the Division of Workers' Compensation (DWC) to request a panel of three qualified doctors who will conduct medical evaluations and provide medical opinions in workers' compensation cases.

Who is required to file request for qme panel?

Any party involved in a workers' compensation case in California can file a request for a Qualified Medical Evaluator (QME) panel. This includes injured workers, employers, insurance companies, and attorneys representing either party.

How to fill out request for qme panel?

To fill out a request for a Qualified Medical Evaluator (QME) panel, you need to download the DWC Form 106 and provide the required information, such as the injured worker's name, case number, date of injury, and specific body part affected. The form should be completed accurately and submitted to the DWC.

What is the purpose of request for qme panel?

The purpose of a request for a Qualified Medical Evaluator (QME) panel is to obtain an impartial medical evaluation and opinion regarding an injured worker's medical condition, treatment, and the extent of permanent disability related to the work-related injury. This helps to resolve disputes and provide fair and appropriate compensation for the injured worker.

What information must be reported on request for qme panel?

The request for a Qualified Medical Evaluator (QME) panel must include the injured worker's name, contact information, case number, date of injury, body parts affected, and specific medical issues or questions to be addressed by the QME. Additionally, any relevant medical reports, records, or documentation should be attached to the request.

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