Get Qme Form

Filling out the Qme Form online is a straightforward process designed to streamline your request for a Qualified Medical Evaluation panel. This guide provides step-by-step instructions to help users effectively complete the form with precision and confidence.

Follow the steps to successfully complete the Qme Form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Enter the date of injury in the designated field. This information is required for processing your request.
3. Provide the specialty of the treating physician, ensuring that you enter this information accurately as it is a required field.
4. Input the claim number in the appropriate field, as it is critical for identifying your case.
5. Specify the specialty requested for the medical evaluation. This is a mandatory section.
6. If known, indicate the opposing party's specialty preference. This can aid in the assignment process.
7. Select the appropriate requesting party by checking one of the provided boxes (applicant's attorney or defense attorney/claims administrator).
8. Identify the reason for requesting the Qme panel by checking one of the available options, as this field is also required.
9. Complete the employee information section by providing the first name, middle initial, last name, and complete mailing address.
10. For users not currently residing in California, enter the California zip code on the date of injury.
11. Answer each of the following questions regarding previous AME/QME exams and medical treatment disputes accurately.
12. If the employee has seen an AME/QME for this injury, provide the required information regarding their name, date of the exam, and primary treating physician.
13. Detail the nature of the dispute that requires resolution in the space provided.
14. Fill out the employee's attorney information accurately, including the first name, last name, and law firm name.
15. Provide the employer and claims administrator information in the respective fields, ensuring all details are complete.
16. Complete the defendant's attorney's section with the required details, including their first name, last name, and law firm name.
17. Review all entries for accuracy and completeness.
18. Once satisfied with the completed form, you can save changes, download, print, or share the form as needed.

Complete your Qme Form online today and ensure a smooth process for your medical evaluation needs.