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State of California DIVISION OF WORKERS\' COMPENSATION MEDICAL UNIT REQUEST FOR QME PANEL UNDER LABOR CODE 4062.1 UNREPRESENTED (For date of injury on or after 1/1/2013 Please print or type) Each
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How to fill out request for qme panel

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How to fill out request for qme panel

01
Obtain a copy of the DWC QME Form 105.
02
Fill out all required fields on the form, including your personal information, information about the injured worker, and the reason for requesting a QME panel.
03
Make sure to include any supporting documentation or medical records that may be relevant to the request.
04
Submit the completed form and any supporting documents to the appropriate DWC office for processing.
05
Wait for confirmation from the DWC that your request has been received and processed.

Who needs request for qme panel?

01
Employers
02
Injured workers
03
Insurance companies
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A request for QME panel is a formal application made to obtain a list of qualified medical evaluators in workers' compensation cases.
The request for QME panel is typically filed by an injured worker or their representative, or the employer's insurance carrier in a workers' compensation case.
To fill out the request for QME panel, an individual must complete the appropriate form, providing necessary details such as the injured worker's information, the type of injury, and the relevant case details.
The purpose of the request for QME panel is to obtain an impartial medical evaluation to assist in resolving disputes regarding the medical status or treatment of an injured worker.
The information that must be reported includes the injured worker's name, date of injury, type of injury, and any other case-specific information required by the form.
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