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State of California DIVISION OF WORKERS COMPENSATION MEDICAL UNIT REQUEST SOMME Panels UNDER LABOR CODE 4062.2 REPRESENTED Request Date Requesting Party (Check one): Applicant s Attorney (or injured

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What is panel qme request form?

The panel qme request form is a document used in workers' compensation cases in California to request a Qualified Medical Evaluator (QME) panel.

Who is required to file panel qme request form?

Any party involved in a workers' compensation case in California may be required to file a panel qme request form.

How to fill out panel qme request form?

To fill out the panel qme request form, you need to provide information about the injured worker, the requesting party, the case details, and the desired specialty.

What is the purpose of panel qme request form?

The purpose of the panel qme request form is to request a panel of QMEs from which an evaluator will be selected to provide a medical evaluation in a workers' compensation case.

What information must be reported on panel qme request form?

The panel qme request form typically requires information such as the injured worker's name, date of injury, case number, and the specialty of the desired QME.

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