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Attached is a copy of my written proposal for one or more physicians to be an AME. Employee or Attorney Signature Print name also Date Adjuster/Employer or Attorney Signature cc QME or AME FOR DWC USE ONLY Original panel source QME Form 113 rev. Mar. 2007. STATE OF CALIFORNIA DEPARTMENT OF INDUSTRIAL RELATIONS DIVISION OF WORKERS COMPENSATION - MEDICAL UNIT P. O. Box 71010 Oakland CA 94612 510 286-3700 or 800 794-6900 Fax 510 622-3467 date NOTICE OF DENIAL OF REQUEST FOR TIME EXTENSION...
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What is qme form 113?
QME Form 113 is a form used in California's workers' compensation system to report on Qualified Medical Evaluators (QMEs) and their evaluations.
Who is required to file qme form 113?
Employers, insurance carriers, and claims administrators are required to file QME Form 113.
How to fill out qme form 113?
QME Form 113 can be filled out by providing the required information about the QME and their evaluations, including the QME's name, contact information, evaluation details, and any supporting documentation.
What is the purpose of qme form 113?
The purpose of QME Form 113 is to report and document Qualified Medical Evaluations in workers' compensation cases in California.
What information must be reported on qme form 113?
QME Form 113 requires reporting of the QME's name, contact information, evaluation details, documentation, and any other relevant information related to the evaluation.
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