Qme Form 105A – Fill Out and Use This PDF

Qme Form 105A is a form that helps injured workers access their rightful benefits in the California workers’ compensation system. This form, known as an Advanced Beneficiary Notice–or ABN–enables doctors to bill costs directly to workers rather than to the insurance provider. An ABN outlines how much of an elective or voluntary item an insurance plan pays for and widens a patient's options for obtaining medical care in complex cases. By receiving a Qme Form 105A, patients have more control when it comes to selecting a doctor. They can choose from providers who are approved by their one of the state databases and listed on the California Physicians List (CPL). This enables injured workers to get treatment nearer to their home rather than travelling within an area funded by their insurer. Adequate medical care should be accessible for all individuals, no matter their employment and monetary situation – Qme Form 105A allows those working through difficult situations to get back on their feet, confident in knowing they are being fairly compensated for any services rendered.

Qme Form 105A PDF Details

Understanding the different options available to you when it comes to filing taxes can be tricky and time-consuming. With many forms, rates, and regulations to consider, tax season can be a confusing experience. One form that many people may not recognize is the Qme Form 105A. This form is part of the federal Qualified Medicare Beneficiary (QMB) program for eligible individuals who need additional assistance with their Medicare costs. Keep reading for a full breakdown on what this form does and how to file it correctly!

Question	Answer
Form Name	Qme Form 105A
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	105a, 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

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:
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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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:

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.

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Qme Form 105A – Fill Out and Use This PDF

Qme Form 105A PDF Details

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