REQUEST FOR QUALIFIED MEDICAL EVALUATOR (QME) PANEL

(Workers' Compensation Medical-Legal Evaluation)

PART 1: REQUEST INFORMATION

DATE OF REQUEST: [DATE]

CLAIM NUMBER: [NUMBER]

WCAB CASE NUMBER (if applicable): [ADJ NUMBER]

REQUESTING PARTY:
☐ Injured Worker (Applicant)
☐ Insurance Carrier/Employer (Defendant)

PART 2: CLAIMANT INFORMATION

2.1 Injured Worker

Name: [FULL NAME]

Date of Birth: [DATE]

Social Security Number: [XXX-XX-XXXX]

Address:
[STREET ADDRESS]
[CITY], [STATE] [ZIP CODE]

Phone: [PHONE NUMBER]

Email: [EMAIL]

Primary Language: [LANGUAGE]
☐ Interpreter needed (Language: [LANGUAGE])

2.2 Representation Status

Is the Injured Worker Represented by an Attorney?

☐ No - Injured worker is unrepresented (pro per)

☐ Yes - Injured worker is represented
Attorney Name: [NAME]
Firm: [FIRM]
Phone: [PHONE]

PART 3: EMPLOYER/INSURANCE INFORMATION

3.1 Employer

Employer Name: [EMPLOYER NAME]

Address:
[STREET ADDRESS]
[CITY], [STATE] [ZIP CODE]

3.2 Insurance Carrier/Claims Administrator

Carrier/Administrator Name: [NAME]

Claim Number: [NUMBER]

Claims Examiner: [NAME]

Address:
[STREET ADDRESS]
[CITY], [STATE] [ZIP CODE]

Phone: [PHONE]

Fax: [FAX]

Email: [EMAIL]

3.3 Defense Attorney (if any)

Name: [NAME]

Firm: [FIRM]

Address: [ADDRESS]

Phone: [PHONE]

PART 4: INJURY INFORMATION

4.1 Date of Injury

Date of Injury: [DATE]

Type of Injury:
☐ Specific injury (single incident)
☐ Cumulative trauma (period: [START DATE] to [END DATE])

4.2 Body Parts in Dispute

Body Parts for Which QME Evaluation is Requested:

☐ Head/Brain
☐ Face/Jaw
☐ Eyes
☐ Ears (Hearing)
☐ Neck/Cervical Spine
☐ Thoracic Spine
☐ Lumbar Spine
☐ Shoulder: ☐ Left ☐ Right ☐ Both
☐ Upper Arm: ☐ Left ☐ Right ☐ Both
☐ Elbow: ☐ Left ☐ Right ☐ Both
☐ Forearm/Wrist: ☐ Left ☐ Right ☐ Both
☐ Hand/Fingers: ☐ Left ☐ Right ☐ Both
☐ Chest/Ribs
☐ Abdomen/Internal Organs
☐ Hip/Pelvis: ☐ Left ☐ Right ☐ Both
☐ Thigh/Knee: ☐ Left ☐ Right ☐ Both
☐ Lower Leg/Ankle: ☐ Left ☐ Right ☐ Both
☐ Foot/Toes: ☐ Left ☐ Right ☐ Both
☐ Skin (Dermatology)
☐ Cardiovascular System
☐ Pulmonary/Respiratory System
☐ Psychiatric/Psychological
☐ Other: [SPECIFY]

4.3 Primary Treating Physician

PTP Name: [NAME]

Specialty: [SPECIALTY]

Address: [ADDRESS]

Phone: [PHONE]

PART 5: MEDICAL SPECIALTY REQUESTED

5.1 Specialty Selection

Requested QME Specialty:

☐ Orthopedic Surgery
☐ Neurology
☐ Neurosurgery
☐ Internal Medicine
☐ Occupational Medicine
☐ Pain Medicine
☐ Physical Medicine & Rehabilitation (PM&R)
☐ Psychiatry
☐ Psychology
☐ Chiropractic
☐ Cardiology
☐ Pulmonology
☐ Dermatology
☐ Ophthalmology
☐ Otolaryngology (ENT)
☐ Podiatry
☐ General Surgery
☐ Other: [SPECIFY]

5.2 Reason for Specialty Selection

[EXPLAIN WHY THIS SPECIALTY IS APPROPRIATE FOR THE DISPUTED ISSUES]

____________________________________________________________________________

____________________________________________________________________________

PART 6: ISSUES IN DISPUTE

6.1 Medical Issues Requiring QME Evaluation

☐ Causation (AOE/COE)
Whether the injury/condition arose out of and in the course of employment

☐ Diagnosis
Proper diagnosis of the claimed condition(s)

☐ Extent of Injury
Whether additional body parts are industrially related

☐ Medical Treatment
Whether proposed treatment is reasonable and necessary

☐ Temporary Disability Status
Whether applicant is temporarily disabled from work

☐ Permanent and Stationary Status
Whether applicant has reached maximum medical improvement

☐ Permanent Disability
Whole person impairment rating and work restrictions

☐ Work Restrictions
Permanent limitations and restrictions

☐ Apportionment
Whether disability should be apportioned to non-industrial causes

☐ Future Medical Care
Need for ongoing medical treatment

☐ Return to Work
Whether applicant can return to usual and customary occupation

☐ Other: [SPECIFY]
____________________________________________________________________________

6.2 Specific Questions for QME

1. [QUESTION 1]

2. [QUESTION 2]

3. [QUESTION 3]

4. [QUESTION 4]

5. [QUESTION 5]

PART 7: GEOGRAPHIC LOCATION

7.1 Preferred Location

Injured Worker's Residence:
City: [CITY]
County: [COUNTY]
Zip Code: [ZIP CODE]

Preferred Evaluation Location:
☐ Within 75 miles of residence
☐ Other location: [SPECIFY]

7.2 Accessibility Requirements

☐ No special accessibility requirements

☐ Special requirements needed:
☐ Wheelchair accessible
☐ Public transportation accessible
☐ Ground floor/elevator access
☐ Other: [SPECIFY]

PART 8: LANGUAGE REQUIREMENTS

8.1 Language Needs

Does the injured worker require an interpreter?

☐ No - Speaks English fluently

☐ Yes - Interpreter needed
Language: [LANGUAGE]

8.2 Written Communications

Language preference for written communications:
☐ English
☐ Other: [LANGUAGE]

PART 9: AGREED MEDICAL EVALUATOR (AME) ATTEMPT

9.1 AME Status (Represented Applicants Only)

Has an attempt been made to agree on an AME?

☐ Not applicable - Applicant is unrepresented

☐ Yes - AME agreed upon: [PHYSICIAN NAME]
(No QME panel needed)

☐ Yes - Unable to agree on AME
Date of objection/impasse: [DATE]
Reason: [EXPLAIN]

☐ No response to AME proposal within 10 days

PART 10: PRIOR EVALUATIONS

10.1 Previous Medical-Legal Evaluations

Has a QME/AME evaluation already been performed for this claim?

☐ No

☐ Yes - Prior evaluation details:

10.2 Reason for New Panel Request

☐ Not applicable - No prior QME

☐ Different body parts in dispute

☐ New and further disability

☐ Prior report was deficient

☐ Other: [EXPLAIN]
____________________________________________________________________________

PART 11: DOCUMENTS TO PROVIDE TO QME

11.1 Required Medical Records

The following records will be provided to the QME:

☐ Complete medical records from PTP
☐ Hospital records
☐ Diagnostic imaging reports and films
☐ Prior QME/AME reports
☐ Deposition transcripts
☐ Prior workers' compensation records
☐ Employment records
☐ Job description/physical demands analysis
☐ Wage records
☐ Other: [SPECIFY]

11.2 Record Exchange

Date records provided to opposing party: [DATE]

Date records received from opposing party: [DATE]

PART 12: CERTIFICATION

12.1 Requesting Party Certification

I, [NAME], certify that:

☐ A medical dispute exists that requires evaluation by a Qualified Medical Evaluator.

☐ The information provided in this request is true and correct.

☐ I will provide all relevant medical records to the QME as required by law.

☐ I understand the QME selection process and will comply with applicable regulations.

For Represented Applicants:
☐ An attempt was made to agree on an AME, and the parties were unable to agree.

Signature: _________________________________

Printed Name: [NAME]

Title/Capacity: [TITLE]

Date: [DATE]

PART 13: FILING INSTRUCTIONS

13.1 Where to File (California)

Division of Workers' Compensation
Medical Unit - QME Panel Request

Online: [DWC Website - EAMS]

Mail:
Division of Workers' Compensation
Attention: Medical Unit
[ADDRESS]
[CITY], CA [ZIP]

Fax: [FAX NUMBER]

13.2 Filing Fee

☐ No filing fee for QME panel request

13.3 Processing Time

Typical processing time for QME panel: [10-20 business days]

PART 14: QME SELECTION PROCESS

14.1 Panel Selection (After Panel is Received)

Date Panel Received: [DATE]

Panel Number: [NUMBER]

QME Panel Members:

14.2 Strike Process

Strike 1 (Applicant): Physician #[NUMBER] - [NAME]

Strike 2 (Defendant): Physician #[NUMBER] - [NAME]

Selected QME: Physician #[NUMBER] - [NAME]

Date Selection Made: [DATE]

14.3 Unrepresented Applicant Selection

Selected QME: [NAME]

Date of Selection: [DATE]

PART 15: SCHEDULING THE QME APPOINTMENT

15.1 Appointment Information

QME Selected: [NAME]

Contact for Scheduling:
Phone: [PHONE]
Fax: [FAX]
Email: [EMAIL]

Appointment Date: [DATE]

Appointment Time: [TIME]

Appointment Location:
[ADDRESS]
[CITY], [STATE] [ZIP]

15.2 Pre-Evaluation Requirements

☐ All medical records sent to QME by: [DATE]
☐ Interpreter arranged (if needed)
☐ Transportation arranged (if needed)
☐ Injured worker notified of appointment

PART 16: STATE-SPECIFIC INFORMATION

California:

Medical Unit Contact:
Division of Workers' Compensation
Medical Unit
Phone: 1-800-794-6900
Website: www.dir.ca.gov/dwc/medicalunit

QME Regulations:
Title 8, California Code of Regulations, Sections 1-199

Key Deadlines:
- QME must be selected within 10 days of panel issuance
- QME has 30 days from evaluation to issue report

[YOUR STATE]:

[INSERT STATE-SPECIFIC MEDICAL EVALUATOR INFORMATION]

[END OF DOCUMENT]