Qme Form 105 PDF Details

In California, managing workers' compensation cases involves a meticulous process, especially when disputes arise regarding medical determinations made by treating physicians. At the heart of this process lies the QME 105 form, a crucial document used under Labor Code § 4062.1 for cases where an employee is unrepresented and a disagreement surfaces. This form serves as a formal request to the Division of Workers' Compensation - Medical Unit for a Qualified Medical Examiner (QME) panel. Primarily, it is used to challenge decisions related to an employee's need for medical treatment, the compensability of an injury, or disputes over permanent disability ratings. Required to accompany each submission are the underlying objection to the treating physician’s medical determination or a notification of the necessity for an examination to ascertain compensability. Besides the essential dispute information, the form mandates details such as the date of injury, claim number, and the specific medical specialty requested for the panel. It also collects comprehensive information regarding the injured employee, including past interactions with a QME and current disputes about medical treatments. Additionally, the employer or claim administrator's information, alongside the documentation of the declared service method for form submission, underscores the procedural rigor in ensuring all parties are duly notified. Distilling this complex procedure into accessible terms, the QME 105 form embodies the structured approach to resolving medical disputes in workers' compensation cases, ensuring fairness and transparency in the evaluation of an injured worker's needs.

QuestionAnswer
Form NameQme Form 105
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namesQMEForm105new blank qme form 105

Form Preview Example

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 form shall be accompanied by an objection to a medical determination made by the treating physician or a notice that there is a need for an examination to determine compensability. Each employer or claims administrator submitting this form to request

a QME panel must attach a copy of the correspondence and required notices sent to the injured employee with the panel request

form.

Date of Injury (Required):

 

Claim Number (Required):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Specialty Requested (Required):

 

 

 

 

 

 

 

 

 

 

 

 

 

Requesting party

(Required) (Check one box only)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Injured Employee

 

Defense Attorney

 

 

Claims Administrator

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Reason QME panel is being requested (Check one box only)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

§ 4060 (compensability exam)

§ 4061 (permanent disability dispute)

 

 

§ 4062 (non medical treatment dispute under 4062)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employee Information (Required)

 

 

 

 

First Name:

 

 

 

 

 

Middle Initial:

 

Last Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street Address or P.O. Box:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City:

 

 

State:

 

Zip Code:

 

 

 

 

 

 

 

 

Daytime Phone No:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If currently not living in state, enter the California zip code on date of injury:

If never resided in state, enter the California zip code agreed on for the evaluation:

Has the employee ever received a QME panel before?

 

Yes

 

No If yes, Panel Number (If known):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of QME seen:

 

 

 

 

 

 

 

 

Date of Exam:

 

Date of Injury:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Has that claim been settled or resolved?

Yes

No Is this a dispute about a current need for medical treatment?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employer and Claims Administrator Information (Required)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

Employer:

Claims Administrator Company Name:

Claims Examiner Name:

 

Street Address or P.O. Box:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City:

 

 

 

State:

 

Zip Code:

 

Phone No.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Defendant's Attorney

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

First Name

 

 

 

 

 

 

Last Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Law Firm Name

Address/PO Box (Please leave blank spaces between numbers, names or words)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

State Zip Code

 

 

 

Phone Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Print Name of Requestor

 

 

 

 

 

 

 

 

 

Signature of Requestor

 

 

 

 

 

 

 

 

 

The completed form must be mailed to: Division of Workers' Compensation-Medical Unit- P.O. Box 71010, Oakland, CA 94612

QME Form 105a (1/2013) (7/2013)

(510) 286-3700 or (800) 794-6900

Note:Each employer or claims administrator submitting this form to request a QME panel must attach a copy of the correspondence and required notices sent to the injured employee with the panel request form.

Declaration of Service

I declare that I am a resident of or employed in the county where the mailing took place. I am over the age of eighteen years and I am not a party to this case, my business or residence address is:

On

, I served this QME 105 form, the original, or a true and correct copy of the original, which

 

is attached, on each of the persons or firms named below, by placing it in a sealed envelope, addressed to the person

or firm named below, and by:

A

B

C

D

E

Method of

Service

Method of

Service

Method of

Service

Method of

Service

depositing the sealed envelope with the U. S. Postal Service with the postage fully prepaid.

placing the sealed envelope for collection and mailing following our ordinary business practices. I am readily familiar with this business’s practice for collecting and processing correspondence for mailing. On the same day that correspondence is placed for collection and mailing, it is deposited in the ordinary course of business with the U. S. Postal Service in a sealed envelope with postage fully prepaid.

placing the sealed envelope for collection and overnight delivery at an office or a regularly utilized drop box of the overnight delivery carrier.

placing the sealed envelope for pick up by a professional messenger service for service (Messenger must return to you a completed declaration of personal service.)

personally delivering the sealed envelope to the person or firm named below at the address show below.

Person or firm served

Street Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City:

State

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Person or firm served

Street Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

State

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Person or firm served

Street Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

State

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Person or firm served

Street Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

State

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.

Date:at

Type or print name

, California.

Signature _____________________________________________

QME Form 105 (7/2013)

For Use with the QME Panel Request Form 105a

MD/DO SPECIALTY CODES

MAI

 

Allergy and Immunology

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MDE

 

Dermatology

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MEM

 

Emergency Medicine

MFP

 

 

Family Practice

 

 

MPM

 

General Preventive Medicine

 

MHH

 

Hand

 

MMM

Internal Medicine

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MMV

 

 

Internal Medicine- Cardiovascular Disease

 

MME

 

Internal Medicine- Endocrinology Diabetes and

 

 

 

 

 

 

 

Metabolism

 

MMG

 

Internal Medicine

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MMH

 

Internal Medicine-Hematology

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MMI

 

Internal Medicine-Infectious Disease

 

MMN

 

Internal Medicine-Nephrology

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MMP

 

Internal Medicine-Pulmonary Disease

 

MMR

Internal Medicine-Rheumatology

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MNB

 

Spine

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MPN

 

Neurology

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MNS

 

Neurological Surgery (other than Spine)

MOG

 

Obstetrics and Gynecology

 

MPO

 

Occupational Medicine

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MMO

 

Oncology- Orthopaedic Surgery Internal

 

 

 

 

 

 

Medicine or Radiology

 

 

MOP

 

Ophthalmology

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MOS

 

Orthopaedic Surgery(other than Spine or Hand)

MTO

 

Otolaryngology

 

 

 

 

 

 

 

 

 

 

 

 

 

MPA

 

Pain Medicine

 

MHA

 

Pathology

 

 

 

 

 

 

 

 

 

 

 

MPR

 

Physical Medicine & Rehabilitation

 

MPS

 

Plastic Surgery (other than Hand)

MPD

 

Psychiatry (other than Pain Medicine)

MSY

 

Surgery(other than Spine or Hand)

 

MSG

 

Surgery-General Vascular

 

MTS

 

Thoracic Surgery

 

MTT

 

Toxicology

 

MUU

 

Urology

 

NON-MD/DO SPECIALTY CODES

ACA Acupuncture

DCH Chiropractic

DEN Dentistry

OPT Optometry

POD Podiatry

PSY Psychology

PSN

 

Psychology -Clinical Neuropsychology

Do not file this page with your form!

QME Form 105a (1/2013) (7/2013)

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Filling out this form will require attentiveness. Make certain every single blank is done correctly.

1. Whenever filling out the Qme Form 105, ensure to complete all of the important blanks within the corresponding section. This will help expedite the work, allowing your information to be handled efficiently and appropriately.

Tips on how to fill out Qme Form 105 portion 1

2. Once your current task is complete, take the next step – fill out all of these fields - Name of QME seen, Date of Exam, Date of Injury, Has that claim been settled or, Yes, Is this a dispute about a current, Yes, Employer and Claims Administrator, Employer, Claims Administrator Company Name, Claims Examiner Name, Street Address or PO Box, City, State, and Zip Code with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

How one can prepare Qme Form 105 step 2

Many people often make mistakes while filling in Street Address or PO Box in this area. You need to go over whatever you enter right here.

3. In this stage, check out City, Date, State, Zip Code, Phone Number, Print Name of Requestor, Signature of Requestor, and The completed form must be mailed. Each of these will have to be filled in with greatest attention to detail.

Best ways to fill out Qme Form 105 stage 3

4. The form's fourth part comes with these particular blanks to consider: I declare that I am a resident of, On I served this QME form the, or firm named below and by, depositing the sealed envelope, placing the sealed envelope for, placing the sealed envelope for, placing the sealed envelope for, personally delivering the sealed, Method of Service, Person or firm served, and Street Address.

placing the sealed envelope for, On I served this QME form the, and placing the sealed envelope for of Qme Form 105

5. And finally, this last segment is precisely what you will have to complete before closing the document. The fields in this case are the following: Method of Service, Method of Service, Method of Service, City, State, Zip Code, Person or firm served, Street Address, City, State, Zip Code, Person or firm served, Street Address, City, and State.

Filling out part 5 of Qme Form 105

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