Search results
TO REQUEST A QUALIFIED MEDICAL EVALUATOR (QME) PANEL FOR AN UNREPRESENTED EMPLOYEE: Complete this form (print or type the information). Sign and date at bottom.
Online QME Form 106 Panel Request. In order to provide a more efficient means of requesting and receiving QME panels, the Division of Workers' Compensation (DWC) implemented a new online panel process for represented initial panel requests on Oct. 1, 2015. How does it work?
DIVISION OF WORKERS' COMPENSATION - MEDICAL UNIT REQUEST FOR QME PANEL UNDER LABOR CODE § 4062.2. REPRESENTED - for injuries occurring prior to January 1, 2005. (Please print or type) Claim Number (Required): Specialty of Treating Physician (Required): Print Form. Reset Form. Specialty Requested (Required):
Designate the speciality for the QME panel requested: use the three letter codes outlined on page three of either QME form 105 or 106. State the specialty preferred by the opposing party, if known. State the specialty of the treating physician.
One physician from the list must be selected. The QME selected will do a medical examination and write a report. This QME report provides an independent, second medical opinion on all of the disputed and unresolved issues in the case that need a medical opinion.
Please email the Medical Unit at MUHelpdesk@dir.ca.gov for assistance. X. There was a problem retrieving information from the QME database. Please refresh this page. If the problem persists, contact the Medical Unit at MUHelpdesk@dir.ca.gov for assistance. Continue . * indicates a required field. 0.49 10192015. Panel.
Use QME Form 106 only in cases in which the injured employee is represented by an attorney. To request a panel of three QMEs in a represented case, the parties first must have attempted to agree on an Agreed Medical Evaluator to resolve a disputed issue as provided by Labor Code Section 4062.2.
