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Get Qme Form 105

Insurer/TPA Claims Adjuster if known Attorney/Representative Claim No. MEDICAL SPECIALITY REQUESTED Please list ONLY ONE insert three letter code from the list on the back of this page Specialty Requested Requestor name print Signature of Requestor Note Any employer/claims administrator using this form to request a QME panel must attach a copy of correspondence sent to the injured employee furnishing the form and advising the employee how to requ.

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