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Method of Service Person or firm served I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. at Type or print name Signature California. For Use with the QME Panel Request Form 106a MD/DO SPECIALTY CODES NON-MD/DO SPECIALTY CODES MAI Allergy and Immunology ACA Acupuncture MDE Dermatology DCH Chiropractic MEM Emergency Medicine DEN Dentistry MFP Family Practice OPT Optometry MPM Gener.

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Once a QME evaluation is requested, the DWC will randomly generate a panel of possible QMEs to determine the extent of the work-related injury. The purpose of a QME evaluation is to decide whether you have any permanent or long-term disabilities as a result of your injury, and what future medications you may need.

(Unrepresented Employee) TO REQUEST A QUALIFIED MEDICAL EVALUATOR (QME) PANEL FOR AN UNREPRESENTED EMPLOYEE: 1. Complete this form (print or type the information).

Qualified medical evaluator process. Qualified medical evaluators (QMEs) are qualified physicians who are certified by the Division of Workers' Compensation - Medical Unit to examine injured workers to evaluate disability and write medical-legal reports.

The amount of your weekly permanent disability payments equals two-thirds of your average weekly wage at the time of your injury, limited by the minimum and maximum rates stated by the California Labor Code.

The impairment rating is a percentage that represents the extent of a whole person impairment of the employee, based on the organ or body function affected by a covered illness or illnesses.

The QME report is used to determine a disability rating. The rating will range from 0% disability (no functional impairment) up to 100% disability (permanently and totally disabled).

Qualified medical evaluators (QMEs) are qualified physicians who are certified by the Division of Workers' Compensation - Medical Unit to examine injured workers to evaluate disability and write medical-legal reports. The reports are used to determine an injured worker's eligibility for workers' compensation benefits.

They will examine you and all your medical records to determine the extent of your work-related injury. They will decide if you have any permanent disability and what future medical care you may need. It is important that the doctor has all your medical records.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232