Qme Form 31 7 PDF Details

In the intricate landscape of workers' compensation in California, the QME 31 7 form plays a pivotal role in ensuring that disputes regarding an employee's medical condition and treatment are resolved with the input of qualified medical experts. Managed by the State of California Division of Workers' Compensation - Medical Unit, this form allows for the request of an additional panel of Qualified Medical Evaluators (QMEs) under specific regulations, particularly the 8 Cal. Code of Regulations section 31.7. This process necessitates clarity and precision, starting with the identification of the requesting party and extending through intricate details such as the original panel number, claim number, and the detailed rationale behind the request for an additional panel. Integral to this form is also the requirement for a detailed declaration of service, ensuring that all relevant parties are duly notified. Moreover, it tailors the medical expertise needed by allowing for the specification of the medical specialty requested, drawn from an extensive list that includes but is not limited to allergy & immunology, dermatology, internal medicine, and psychology, catering to the diverse range of medical issues that might arise in the context of workers' compensation claims. Understanding the QME 31 7 form is crucial for parties involved in disputes over medical conditions in workers' compensation cases, as it directly influences the timeliness and appropriateness of the evaluation process, potentially impacting the resolution of such disputes.

QuestionAnswer
Form NameQme Form 31 7
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other namesRequestor, 31 7 additional panel form, qme form 31 7, 2013

Form Preview Example

State of California

Division of Workers' Compensation - Medical Unit

Additional Panel Request-8 Cal. Code of Regulations section 31.7

(Please print or type)

Requesting Party (Required)

Original panel number (Required)

 

Claim number (Required)

Joint request

Applicant's Attorney/Injured Worker

Defense Attorney/Claims Administrator

Employee first name (Required)

 

Middle

 

 

Employee last name (Required)

 

EAMS number

 

 

 

Initial

 

(Required if a case is filed)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Reason for the additional panel request (Required)

A written agreement between the parties in a represented case.

(Please attach a signed joint letter or jointly sign the bottom of this form)

The acupuncturist QME selected advised the parties that disability is in issue and a QME is a different specialty is necessary.

(Please attach copy of the letter from the AME/QME.)

Indicate the specialties you are requesting. Each specialty request must be justified by the reason listed above.

Specialty to be issued

Specialty to be issued

Specialty to be issued

Date of Request:

 

Name of Requestor (Required)

 

Signature of Requestor:

(mm/dd/yyyy)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Requestor Address (Required)

State (Required)

 

Zip Code (Required)

 

Name of Requestor

 

Signature of Requestor:

 

 

 

 

 

 

 

 

 

 

 

 

 

Requestor Address

State

 

 

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

QME form 31.7(7/2013)

Declaration of Service

I declare that I am a resident of or employed in the county where the mailing took place. I am over the age of eighteen years and I am not a party to this case, my business or residence address is:

On

, I served this Additional Panel Request form, the original, or a true and correct copy of the

 

original, which is attached, on each of the persons or firms named below, by placing it in a sealed envelope,

addressed to the person or firm named below, and by:

A

B

C

D

E

Method of

Service

depositing the sealed envelope with the U. S. Postal Service with the postage fully prepaid.

placing the sealed envelope for collection and mailing following our ordinary business practices. I am readily familiar with this business’s practice for collecting and processing correspondence for mailing. On the same day that correspondence is placed for collection and mailing, it is deposited in the ordinary course of business with the U. S. Postal Service in a sealed envelope with postage fully prepaid.

placing the sealed envelope for collection and overnight delivery at an office or a regularly utilized drop box of the overnight delivery carrier.

placing the sealed envelope for pick up by a professional messenger service for service (Messenger must return to you a completed declaration of personal service.)

personally delivering the sealed envelope to the person or firm named below at the address show below.

Person or firm served

 

 

Street Address

 

 

 

 

 

 

 

 

 

City

 

State

 

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Method of

Person or firm served

Street Address

 

Service

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

State

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Method of

Person or firm served

Street Address

 

Service

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

State

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Method of

Person or firm served

Street Address

 

Service

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

State

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.

Date:at

Type or print name

, California.

Signature _____________________________________________

QME Specialty Codes

 

 

 

 

 

 

 

MD/DO Specialty Codes

 

 

 

NON-MD/DO Specialty Codes

 

MAI

 

Allergy & Immunology

ACA

Acupuncture

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MDE

 

Dermatology

 

DCH

 

Chiropractic

 

MEM

 

Emergency Medicine

DEN

Dentistry

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MFP

 

 

Family Practice

 

 

OPT

 

Optometry

 

MPM

 

General Preventive Medicine

POD

Podiatry

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MHH

 

Surgery - Hand

 

 

PSY

 

Psychology

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MMM

Internal Medicine

 

PSN

 

Psychology - Clinical Neuropsychology

MMV

Internal Medicine - Cardiovascular Disease

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MME

 

 

Internal Medicine – Endocrinology Diabetes &

 

 

 

 

 

 

 

 

 

 

 

 

Metabolism

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MMG

 

Internal Medicine - Gastroenterology

 

 

 

 

 

 

 

 

 

 

MMH

 

Internal Medicine - Hematology

 

 

 

 

 

 

 

 

 

 

MMI

 

Internal Medicine - Infectious Disease

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MMO

 

Internal Medicine - Medical Oncology

 

 

 

 

 

 

 

 

 

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 & Gynecology

 

 

 

 

 

 

 

 

 

MPO

 

 

Occupational Medicine

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MOS

 

Orthopaedic Surgery (other than Spine or Hand)

 

 

 

 

 

 

 

 

 

MTO

 

Otolaryngology

 

 

 

 

 

 

 

 

 

MPA

 

Pain Medicine

 

 

 

 

 

 

 

 

 

 

 

MHA

 

Pathology

 

 

 

 

 

 

 

 

 

 

MPR

 

Physical Medicine & Rehabilitation

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MPD

 

 

Psychiatry (other than Pain Medicine)

 

 

 

 

 

 

 

 

 

MSY

 

Surgery (other than Spine or Hand)

 

 

 

 

 

 

 

 

 

MSG

 

Surgery - General Vascular

 

 

 

 

 

 

 

 

 

 

MTS

 

Thoracic Surgery

 

 

 

 

 

 

 

 

 

 

MTT

 

Toxicology

 

 

 

 

 

 

 

 

 

 

MUU

 

Urology

 

 

 

 

 

 

 

 

 

 

Do Not file this page with your additional panel request!

QME form 31.7(7/2013)

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1. Complete your additional panel request form with a number of necessary blanks. Consider all of the information you need and ensure there is nothing forgotten!

Writing segment 1 in California

2. Once the last segment is finished, you need to put in the essential details in Specialty to be issued, Specialty to be issued, Date of Request mmddyyyy, Name of Requestor Required, Signature of Requestor, Requestor Address Required, State Required, Zip Code Required, Name of Requestor, Signature of Requestor, Requestor Address, State, and Zip Code in order to move on further.

Name of Requestor Required, State, and Zip Code in California

3. The following portion focuses on I declare that I am a resident of, On I served this Additional Panel, addressed to the person or firm, depositing the sealed envelope, placing the sealed envelope for, placing the sealed envelope for, placing the sealed envelope for, and personally delivering the sealed - fill in all these empty form fields.

Writing section 3 of California

4. To move ahead, this fourth section requires filling out several empty form fields. These comprise of Method of Service, Method of Service, Method of Service, Method of Service, Person or firm served, Street Address, City, State, Zip Code, Person or firm served, Street Address, City, State, Zip Code, and Person or firm served, which you'll find essential to continuing with this particular document.

Writing segment 4 of California

5. Because you near the last parts of the document, you'll notice just a few more requirements that need to be satisfied. Specifically, Method of Service, Person or firm served, Street Address, City, State, Zip Code, I declare under penalty of perjury, Date, Type or print name, Signature, and California should be filled in.

Step no. 5 of completing California

Lots of people frequently get some points incorrect when completing Method of Service in this section. You should reread what you enter right here.

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