Qme Form 105A PDF Details

In navigating the complexities of workers' compensation in California, particularly for those injuries occurring on or after January 1, 2013, the QME Form 105A serves as a critical tool in the resolution of disputes between injured employees and employers or claims administrators. This form, issued by the State of California's Division of Workers' Compensation - Medical Unit, enables either party to request a Qualified Medical Evaluator (QME) panel to examine contested medical issues under Labor Code § 4062.1. Such requests can arise from disputes about the compensability of an injury, permanent disability disagreements, or conflicts surrounding the necessity for medical treatment. The form requires detailed identification of both the requesting party—be it the injured employee, defense attorney, or claims administrator—and the employee, including contact information, the nature of the dispute, and any previous QME evaluations. Accompanying the form is a comprehensive list of medical specialties to ensure the appropriate expertise is consulted in evaluating the case at hand. This process underscores the structured approach California has adopted in mediating the intricacies of workers' compensation claims, aiming to provide clear, fair, and expedient resolutions in what are often complicated and contentious situations.

QuestionAnswer
Form NameQme Form 105A
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other names105a, QME, California, MDE

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)

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 (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

QME Form 105a (1/2013)

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-Gastroenterology

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)

How to Edit Qme Form 105A Online for Free

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Step 2: The tool will give you the ability to customize your PDF document in a variety of ways. Modify it by adding customized text, adjust what is already in the document, and place in a signature - all within the reach of a couple of mouse clicks!

As a way to fill out this document, make sure that you provide the information you need in each and every blank field:

1. It's important to fill out the MMV properly, thus be attentive when filling in the areas comprising these blank fields:

Filling in segment 1 of QME

2. Your next stage would be to fill in these particular fields: Employer and Claims Administrator, Employer, Claims Administrator Company Name, Claims Examiner Name, Street Address or PO Box, City, State, Zip Code, Phone No, First Name, Law Firm Name, Defendants Attorney, Last Name, AddressPO Box Please leave blank, and City.

Last Name, AddressPO Box Please leave blank, and Claims Administrator Company Name of QME

It's very easy to get it wrong while filling in the Last Name, thus make sure to take a second look before you'll send it in.

3. In this specific part, examine Date, State, Zip Code, Print Name of Requestor, Signature of Requestor, The completed form must be mailed, Note Each employer or claims, and QME Form a. These need to be taken care of with utmost precision.

The way to complete QME stage 3

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