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Get Qme Form 31 5

Ber (Required) Claim number (Required) EAMS number (if a case is filed) Date of Injury(Required): Requesting Party (Required) Employee first name (Required) Middle Initial Employee last name (Required) Applicant's Attorney/Injured Worker Defense Attorney/Claims Administrator Indicate the reason why each QME should be replaced. A list of reasons is included in the instructions to this form. Attach documentation to this form to support the request for a new panel or explain the reason for.

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