Qme Form 111 – Fill Out and Use This PDF

STATE OF CALIFORNIA

Division of Workers’ Compensation – Medical Unit

P.O. Box 71010, Oakland, CA 94612

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

QUALIFIED OR AGREED MEDICAL EVALUATOR'S FINDINGS SUMMARY FORM

________________________________________________________________________________________________

EMPLOYEE

1.	Employee Name (First, Middle, Last):	2.	Social Sec. No. (Optional):	3.	Date of Injury
4.	Street Address:	City:	Zip:	5.	Phone:

________________________________________________________________________________________________________

CLAIMS ADMINISTATOR/EMPLOYER

6.	Name:
7.	Street Address:	City:	Zip:	8. Phone:

________________________________________________________________________________________________________

EVENT DATES

9. Date of Appointment Call:

10. Initial Examination Date:

11. Date of Referral for Medical Testing/Consultation:

12. Date AME/QME's Report Served on all Parties:

________________________________________________________________________________________________________

DISPUTED MEDICAL ISSUES AND CONCLUSIONS

13. The following medical issues will be used to determine the patient's eligibility for workers' compensation.

(Check the appropriate box)

		Pending or
Yes	No	Info. Not Sent

a. Has the condition reached permanent and stationary status or maximum medical improvement?

b. Is there permanent impairment/disability?

c. Did work cause or contribute to the injury or illness?

d. If permanent disability exists, is apportionment warranted?

e. Is there a need for current or future medical care?

f. Can this employee now return to his/her usual job?	Yes	No
If yes:
i. Without restrictions	Yes	No,	If YES,	Date: ________________
ii. With restrictions	Yes	No,	If YES,	Date: ________________

________________________________________________________________________________________________________

BASIS FOR CONCLUSIONS	(Check the		appropriate box)
			Pending or
	Yes	No	Info. Not Sent

14. Are there subjective complaints?

15. Are there any abnormal physical or psychological examination findings?

16. Are impairments described and measured using the AMA

Guides?

QME Form 111 (rev. Mar. 2007)

17. If the AMA Guides are used, are percentages of impairment stated?

18. Are there any relevant diagnostic test results (x-ray/laboratory)?

19.What are the diagnoses? (List) _________________________________________________________________________

_________________________________________________________________________________________________________

20.	Were medical records reviewed?
21.	Were other physicians consulted?	Yes	No

________________________________________________________________________________________________________

QME

22.Signature:___________________________________________________________Date:__________________________

23.Name:_____________________________________________________Specialty:_______________________________

24.Street Address:______________________________________City:___________________________Zip:_____________

25.Phone:_______________________________________ Cal. License No.:_______________________________________

Declaration of Service of Medical - Legal Report (Lab. Code § 4062.3(i))

I, _______________________________, declare under penalty of perjury under the laws of the State of California that:

(Print Name)

1.I am over the age of 18 and am employed by _________________________________________________________. (Name of Employer)

2.On _____________________________, I served this QME or AME Summary Form with the attached medical- (Date)

legal report on each of the persons/firms named below, and by using the means of service, indicated below. I further declare that I am readily familiar with the practice of this office, named in (1), above, for collection and processing of correspondence for mailing, which is to deposit envelopes with the U.S. Postal Service on that same day with postage fully prepaid thereon at

________________________________,______________ in the ordinary course of business.

(City)(State)

I further declare that for service by mail, I either deposited this document personally in the U.S. Mail, or that I placed it for normal collection with the office stated in (1) above, in time for collection and processing that same day.

For service by messenger delivery: I further declare that I am familiar with the practice of the office stated in (1), above for messenger delivery, and I caused this document to be placed in a sealed envelope and to be delivered to a courier employed by

____________________________________________________ for personal delivery of each such envelope to the addressee,

within two working days, at the address and on the date indicated in below:

Means of service:	Date:	Addressee and Address:
(e.g. U.S. mail/Certified mail/
Overnight mail/
Service by courier)
____________________	________	_________________________________________________
____________________	________	_________________________________________________
____________________	________	_________________________________________________
_____________________	________	_________________________________________________

Signed this ______________day of _________________,20_____,in the county of _________________, ___________

	(State)
_______________________________________________	____________________________________________
(Signature of Declarant)	(Print Name)
QME Form 111 (rev. Mar. 2007)

Department of Industrial Relations Division of Workers’ Compensation – Medical Unit

PO Box 71010, Oakland, CA 94612 (510) 286-3700 or (800) 794-6900

INSTRUCTIONS

To the QME or AME: You are required by Labor Code section 4062.3(i) to summarize the medical findings from your comprehensive medical-legal evaluation on the form prescribed by the Administrative Director. Please complete the form in its entirety.

Employee Information: Fill in the employee's full name, address, telephone number and date of injury.

Event Dates: Complete dates that patient called for an appointment, date of initial examination, date referred for consultation(s), if any, and date report served on all parties. Supplying these dates is a legal requirement.

Disputed Medical Issues and Conclusions: Complete this section by checking appropriate box and stating what page(s) or section of the medical legal report contain the narrative for details. If diagnostic or laboratory tests have been ordered and the results or a medical records request is pending, check that box. If you cannot render opinions because of pending information, please complete and serve the report to comply with the 30-day time requirement and state what issues could not be evaluated.

Basis for Conclusions: Check appropriate box and give page numbers or section where the narrative in the full report is found. For diagnoses, in addition to page numbers, please briefly summarize the diagnoses in lay terms where possible. Also, list the name and specialty for other physicians who provided information used in the medical legal report.

QME Signature: Remember under the Labor Code, all your reports must be signed under the penalty of perjury. You are required to serve the medical legal report and this form on the employee, the claims administrator (if none, the employer) and the Disability Evaluation Unit (DEU) having jurisdiction over the employee's area of residence.

Declaration of Service of Medical – Legal reports: Labor Code sections 139.2(j)(1)(A) and 4062.3 (i) and section 38 of Title 8 of the California Code of Regulations require the QME or AME to serve the medical-legal report and this form on the employer (or employer’s claims administrator) and the injured worker within 30 days from the commencement of the examination, unless certain conditions are met. Please complete the proof of service to show the date the report was served on the parties.

QME Form 111 (rev. Mar. 2007)