CLEARStateofCaliforniaDivisionofWorkers146CompensationREQUESTFORQUALIF - PDF document

1 QME Form 105 (rev. 09/15) Page 1
QME Form 105 (rev. 09/15) Page 1 CLEARStateofCalifornia,DivisionofWorkers’CompensationREQUESTFORQUALIFIEDMEDICALEVALUATORPANEL(UnrepresentedEmployee)TOREQUEST A QUALIFIEDMEDICALEVALUATOR(QME)PANELFORUNREPRESENTEDEMPLOYEE: DateofInjury:_ ClaimNumber: _ SpecialtyRequested: _ _ (SelectonlyONEspecialty)RequestingParty:EmployeeClaimsAdministratorDefenseAttorney ReasonforQMEPanelRequest Todeterminetheinjuryworkrelated(attachclaimsadministrator’snoticethatclaimwasdenied a copytheclaimsadministrator’s requestfor anevaluation).ObjectionPrimaryTreatingPhysician’sdeterminationregardingtemporarydisability,permanentdisability,the for futuremedicalcare.Workinjuryclaim _ _ _ _ EmployeeInformation FirstName:Middle Initial: Last Name: StreetAddressP.O.Box _ City:State_ ZipCode: _ currentlynotlivingstate,entertheCaliforniazipcodedateinjury: _ neverresidedstate,entertheCaliforniazipcodeagreed onfortheevaluation: Employer/ClaimsAdministratorInformation Employer:_ _ _ _ ClaimsAdministratorCompanyName:_ Adjuster/ContactName(ifknown): _ _ StreetAddressP.O.Box ___________________________________________ City:State:ZipCode:Phone No.: _ RequestorSignature:Date: _ QME Form 105 (rev. 09/15) Page 2 PROOF OF SERVICE Instructions: Complete the Proof ofService. For Employee: Mail the completed signed form and Proof of Service

2 to:Division ofWorkers’ Compensation – M
to:Division ofWorkers’ Compensation – Medical Unit P.O. Box 71010, Oakland, CA 94612(510) 2863700or (800) 7946900 For Employee: Mail or deliver a signed copyof the form and Proof ofService to your Claims Administrator. For Claims Administrator/Defense Attorney:Mail the completed signed form attach a copy of the written objection to an opinion of a treating physician, and Proof of Service, to the Medical Unit with a copy served to the Employee. I declare that I am a resident of or employed inthecounty of , California; I am over the eighteen years. , I served the attachedcompleted Form 105on the following parties: mail to: _ _ Nameof Employee or Claims Administrator _ _ Street Address _ City, State, Zip code handdelivery to: _ _ Name _ _ Street Address _ City, State, Zip code I declare, under penaltyof perjury under the lawsofthe State ofCalifornia, that the foregoing is true and correct. Executed on _ , at _ , California Type or Print Name: _ _ Signature ___________________________________ QME Form 105 (rev. 09/15) Page 3 For Use with the QME Panel Request Form 105 MD/DO SPECIALTY CODES MAA Anesthesiology MAI Allergy & Immunology MPA Pain Medicine MDE Dermatology MAI Dermatology – Allergy & Immunology MEM EmergencyMedicine MTT Emergency Medicine – Toxicology MFP Family Practice MPMGeneral Preventive Medicine MTT General Preventive

3 Medicine – Toxicology MMM Internal Med
Medicine – Toxicology MMM Internal Medicine MAI Internal Medicine- Allergy & Immunology MMV Internal Medicine – Cardiolvascular Disease MME Internal Medicine - Endocrinology Diabetes & Metabolism MMG Internal Medicine – Gastroenterology MMH Internal Medicine – Hematology MMI Internal Medicine – Infectious Disease MMO Internal Medicine – Medical Oncology MMN Internal Medicine – Nephrology MMP Internal Medicine – Pulmonary Disease MMR Internal Medicine – Rheumatology MPN Neurology MPA Neurology – Pain Medicine MNS Neurological Surgery(other thanSpine) MNB Neurological Surgery – Spine MOGObstetrics & Gynecology MOQMedicineOtherwise Qualified MPO Occupational Medicine MTT Occupational Medicine – Toxicology MOP Ophthalmology MOS Orthopedic Surgery(other thanSpine or Hand) MNB Orthopedic Surgery - Spine MHHOrthopedic Surgery - Hand MTO Otolaryngology MHAPathology MPR Physical Medicine& Rehabilitation MPA Physical Medicine & Rehabilitation – Pain Medicine MPS Plastic Surgery (other thanHand) MHHPlastic Surgery – Hand MPD Psychiatry (other than Pain Medicine) MPA Psychiatry – Pain Medicine MSY Surgery(other thanSpine or Hand) MHH Surgery - Hand MSG Surgery- General Vascular MTS ThoracicSurgery MUUUrology MD/DOSPECIALTIES CODES ACA Acupuncture DCH Chiropractic DENDentistry OPT Optometry PODPodiatry PSY Psychology not file this page withyour form! Clear Form Print Form n n n