Qme Form 109 PDF Details

Whether dealing with an injury at work or navigating the complexities of workers' compensation, understanding the intricacies of necessary paperwork is crucial. Among the plethora of forms, the QME Form 109 stands out for its specific function within the California workers’ compensation system. Managed by the State of California's Department of Industrial Relations, specifically its Division of Workers’ Compensation Medical Unit, this form serves an essential role in maintaining the flow and integrity of medical evaluations related to workers’ compensation claims. Essentially, the QME Form 109 is utilized by Qualified Medical Evaluators (QMEs) to notify the Medical Director of the Division of Workers' Compensation about periods of unavailability for panel assignments, which can range from 14 to 90 days. Its importance can't be overstated, as it helps in the planning and rescheduling of medical evaluations, ensuring that individuals involved in workers' compensation cases can receive timely and appropriate medical assessments. The form stipulates clear instructions for noting unavailability, including the option for a QME to resign from their position, and outlines the necessity of listing scheduled evaluations during the said period. It highlights a commitment to transparency and efficiency within the workers’ compensation framework, ensuring that all parties involved are well-informed and adequately prepared for proceeding with evaluations as smoothly as possible.

QuestionAnswer
Form NameQme Form 109
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesQMEForm109 qme notice of unavailability form

Form Preview Example

STATEOFCALIFORNIA

DEPARTMENTOFINDUSTRIALRELATIONS

Divisionof Workers’ Compensation- Medical Unit

P. O. Box71010

 

Oakland, CA 94612

 

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

Fax: (510) 622-3467

QME NOTICE OF UNAVAILABILITY

(Form must be filed 30 days prior to date of unavailability)

TO MEDICAL DIRECTOR, DWC:

(Check the appropriate boxes to indicate that you will be unavailable for panel assignment for a period of 14 days to 90 days.)

Please accept this notice that I will be unavailable for qualified medical evaluation panel assignment

from

to

 

(mm/dd/yyyy)

 

(mm/dd/yyyy)

I wish to resign from my appointment as a QME at all locations on file.

Please remove my name from the List of Qualified Medical Evaluators.

=============================================================================

The above information is for all of my QME office locations.

The above information is only for the QME office location(s) listed below (or attached).

Office Street Address

 

 

 

 

 

 

 

 

City

 

 

 

 

 

Zip

 

 

 

 

 

 

 

 

 

 

 

 

 

Office Street Address

 

 

 

 

 

 

 

 

City

 

 

 

 

 

Zip

 

 

 

 

 

 

 

 

 

 

 

 

Office Street Address

 

 

 

 

 

 

 

 

City

 

 

 

 

 

Zip

Signature

 

 

Date

 

 

 

 

CA. License No.

 

 

 

 

 

 

 

 

 

 

Name (print/type)

 

 

 

 

Phone No.

 

 

 

 

 

 

 

 

 

 

 

 

 

To complete this application, attach a list of all QME and AME examinations scheduled for the period of unavailability. For each case, state whether the exam is being rescheduled or whether you plan to complete the exam and report during the period of unavailability.

(Note: It is not an acceptable reason for unavailability that a QME does not intend to perform evaluations for unrepresented workers. A QME who is unavailable may not schedule or perform QME evaluation examinations (initial or follow up) until the QME returns to active status. A QME may complete reports for evaluation exams performed before becoming unavailable or supplemental reports. A QME who is unavailable for more than 90 days during the QME fee period without good cause may be denied reappointment. If this form is being filed less than 30 days before the QME is to become unavailable, attach a separate explanation of good cause for approving the late application.)

Send this completed form to:

Division of Workers’ Compensation-Medical Unit

P.O. Box 71010

Oakland, CA 94612

(510)286-3700 or (800) 794-6900 Fax (510) 622-3467

QME Form 109 (rev. February 2009)

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1. Begin completing your Qme Form 109 with a number of necessary blanks. Note all the required information and ensure there is nothing overlooked!

Qme Form 109 completion process outlined (step 1)

2. The subsequent stage is usually to fill out these fields: The above information is only for, Office Street Address, City, Office Street Address, City, Office Street Address, City, Zip, Zip, Zip, Date, Signature Name printtype To, CA License No, Phone No, and Note It is not an acceptable.

The above information is only for, Zip, and City in Qme Form 109

3. This step is easy - fill in every one of the fields in Note It is not an acceptable, Send this completed form to, Division of Workers, PO Box, Oakland CA, Fax, and QME Form rev February to complete this segment.

Filling out section 3 of Qme Form 109

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