QME Form 105: Request for Qualified Medical Evaluator Panel (Unrepresented Employee)

Date of Injury, Required or Not: Insert the date the injury occurred. If this is cumulative trauma injury, insert the last date of exposure of or the last date of work. Use MM/DD/YYYY for the date.

The Claim Number is the number assigned to the claim by the claims administrator.

Insert the specialty of the QME requested to perform the examination. Use the three letter code from the list attached to form 105. Select only ONE specialty.

An injured worker has the first opportunity to choose the type of physician to perform the exam.⁠^[2]

Check the appropriate box to indicate who is requesting the evaluation: Employee, Claims Administrator or Defense Attorney.⁠^[2]

Reason for QME Panel Request (check one): To determine if the injury is work-related (attach claims administrator's notice that claim was denied or a copy of the claims administrator's request for an evaluation). Objection to Primary Treating Physician's determination regarding temporary disability, permanent disability, or the need for future medical care. Work injury claim is accepted for one or more body parts, there is a dispute over additional body parts. Other (specify non-medical treatment dispute).

An exam to determine whether the injury is work related is a compensability examination under section 4060. If there is a need to determine if the injury is caused by work (section 4060), then you must attach the notice sent to the other side requesting an examination to determine whether the injury is the responsibility of workers' compensation or attach a copy of the claim's administrator's notice that the claim was denied.

Indicate why the examination is being requested. The boxes in this section indicate the part of the Labor Code that describes the types of examinations. An examination to determine the extent of permanent disability is a permanent disability dispute under 4061. Any other type of dispute is under section 4062.⁠^[2]

This section asks for the name and address of the injured worker.

Enter the Employee First Name, Employee Middle Initial, Employee Last Name, Employee Street Address or P.O. Box, Employee City, Employee State and Employee Zip Code.

If the injured worker no longer lives in California or never lived in California there is a section to state the zip code for the panel.

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.⁠^[2]

This section asks for the name of the employer and the name and address of the claims administrator (insurance company or third-party administrator, for example). Do not file these instructions with your form.

Enter the Employer, the Zip Code of Employer, the Claims Administrator Company Name, the Adjuster/Contact Name (if known), the Street Address or P.O. Box, the City, State, Zip Code and Phone No.⁠^[2]

Requestor Signature and Date: Insert the date the form is completed. Use the MM/DD/YYYY format.⁠^[2]

Complete the attached Proof of Service.

Attached to the form is a proof of service which must be served along with the form. The purpose of the declaration of service is to show the people served with the form. Fill out the proof of service, sign where indicated, and mail to the parties along with the form.

You declare that you are a resident of or employed in the county you enter, California; you are over the age of eighteen years.

After On, you state that you served the attached completed Form 105 on the following parties, by mail to or by hand-delivery to the Name of Employee or Claims Administrator, Street Address and City, State, Zip code.

You declare, under penalty of perjury under the laws of the State of California, that the foregoing Proof of Service on page 2 is true and correct. Fill in Executed on and at, California, Type or Print Name and Signature.⁠^[2]

For Employee: Mail the completed signed form and Proof of Service to Division of Workers' Compensation - Medical Unit P.O. Box 71010, Oakland, CA 94612 (510)286-3700 or (800) 794-6900.

For Employee: Mail or deliver a signed copy of the form and Proof of Service to your Claims Administrator. You are required to send a copy of your completed Form 105 to the employer/insurer as well.⁠^[2]

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.

If you are the claims administrator requesting a QME panel to resolve a dispute under Labor Code section 4061 or 4062, you must attach a written objection indicating the identity of the primary treating physician, the date of the primary treating physician's report that is the subject of the objection and a description of the medical dispute determination that requires a comprehensive medical/legal report to resolve.⁠^[2]

If you do not request a panel within ten (10) days of being asked to do so by the employer/insurer, then the employer/insurer has the right to request the panel and choose the medical specialty.⁠^[2]

In an unrepresented case, the Medical Unit must issue a panel within twenty working days of its receipt of a request to issue a QME panel, or you may select any QME of your choice to do the evaluation within a reasonable geographic distance from your home.

After you receive the panel list of three QME names, you must select a doctor from the list and make an appointment with the chosen physician.

If you do not select a QME from the panel, schedule an appointment with the QME and inform the employer/insurer of the choice within 10 days of the date the Medical Unit issued the panel, you may lose the right to choose the QME and the exam date.

After the examination is scheduled, you must tell the employer/insurer the time and date of your appointment.⁠^[2]