Do you need to make a legal claim against the government? If so, then you may be familiar with Form 116, or Qme. This form is an important part of the legal process and is often used by claimants who want to pursue their case in court. Today, we'll provide an overview of Qme Form 116 requirements, how it works, and its benefits for those making a legal claim against the government. By understanding what this document entails and how it can help with your case – including helping meet deadlines – you'll have all the knowledge you need to complete the form successfully and continue on towards success in your pursuit of justice!
| Question | Answer |
|---|---|
| Form Name | Qme Form 116 |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | form 116, evaluator, physicians, Referral |
STATE OF CALIFORNIA
DEPARTMENT OF INDUSTRIAL RELATIONS
DIVISION OF WORKERS’ COMPENSATION - MEDICAL UNIT
P. O. Box 71010 |
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Oakland, CA 94612 |
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(510) |
Fax: (510) |
(date)
NOTICE OF LATE QME/AME REPORT - NO EXTENSION REQUESTED
(Injured Employee or Attorney) |
(Claims Administrator or Attorney) |
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(address) |
(address) |
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Re: |
(Injured Employee name) v. (Employer/Insurer name) |
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Claim No.: |
|
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QME Panel No.:
Name of QME/AME:
Evaluation Date (or Date of Request for Supplemental Report):
It has come to our attention that the medical/legal evaluation report to be written by your QME, Agreed Panel QME, or AME is late and the evaluator did not obtain approval for an extension of time to complete the report. The parties have two options: 1) you may wait for the report if both parties agree in writing to waive the lateness of the report; or 2) if either party does not agree to wait, you may agree on a new AME (represented cases only) or request a replacement panel QME. If you are represented by an attorney, consult your attorney.
Please advise the Medical Unit and the evaluator within fifteen (15) days of the date of this letter what you wish to do. Sign the form below, mail or fax it to the Medical Unit at P.O. Box 71010, Oakland, CA 94612 or fax (510)
(Check one)
() I wish to waive the lateness of this report and accept the report when it is done.
() I request a new QME panel due to the lateness of the original QME or AME report.
(For represented cases with AME only attach a copy of the first written proposal for one or more physicians to be an AME.)
Employee (or Attorney) Signature |
(Print name also) |
Date |
Claims Administrator (or Attorney) Signature (Print name also) |
Date |
cc: QME, Agreed Panel QME or AME |
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FOR DWC USE ONLY
Original panel source_______Original panel specialty ________ Referral _________
QME Form 116 (rev. February 2009)