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O. Box 71010 Oakland CA 94612 510 286-3700 or 800 794-6900 Fax 510 622-3467 QME APPOINTMENT NOTIFICATION FORM To the Qualified Medical Evaluator You are required by law to give notice on this form when an appointment has been made with you to perform a QME comprehensive medical evaluation. Please complete this form in its entirety. The Administrative Director also requires that you serve this appointment notification form on the employee and the claims administrator or if none the employer and their attorneys in a represented case if known within five 5 business days after having scheduled the injured worker to be seen for a QME comprehensive medical evaluation. You also must use this form if you refer the injured worker for a consultation to advise the parties of the date and time of the appointment with the consulting physician See 8 Cal. Code Regs. PRINT CLEAR STATE OF CALIFORNIA DEPARTMENT OF INDUSTRIAL RELATIONS DIVISION OF WORKERS COMPENSATION - MEDICAL UNIT MAILING ADDRESS P. You are legally required to include the name and address of the employee the name of the employer and claims administrator and the appointment time and date. 32. You may not cancel the appointment less than six 6 calendar days prior to the appointment date except for good cause See 8 Cal* Code Regs. 34. If you reschedule an appointment review regulation 34 and the ethical rules in regulation 41 See 8 Cal Code Regs. 34 and 41 a 7 and a 8. EMPLOYEE INFORMATION NAME ADDRESS City State PHONE Zip SOCIAL SECURITY No* Social Security Number is for record-keeping purposes only. DATE OF INJURY PANEL No* CLAIM/CASE No* CLAIMS ADMINISTRATOR INFORMATION COMPANY APPOINTMENT INFORMATION DATE OF APPOINTMENT CALL TIME OF LOCATION OF APPOINTMENT CERTIFIED INTERPRETER REQUIRED LANGUAGE COPY TO EMPLOYEE and employee s attorney if known SIGNATURE OF QME QME NAME print/type ADDRESS AND PHONE Note to Claims Administrator The Administrative Director s regulation 10160 requires you to forward a completed DWC-AD form 101 DEU Request for Summary Rating Determination of Qualified Medical Evaluator s Report see 8 Cal* Code Regs. 10160 and 10161 together with all medical reports and medical records prior to the scheduled examination with the QME* You must also provide the employee with a DWC-AD form 100 DEU Employee s Disability Questionnaire See 8 Cal* Code Regs. 32. You may not cancel the appointment less than six 6 calendar days prior to the appointment date except for good cause See 8 Cal* Code Regs. 34. If you reschedule an appointment review regulation 34 and the ethical rules in regulation 41 See 8 Cal Code Regs. 34. If you reschedule an appointment review regulation 34 and the ethical rules in regulation 41 See 8 Cal Code Regs. 34 and 41 a 7 and a 8. EMPLOYEE INFORMATION NAME ADDRESS City State PHONE Zip SOCIAL SECURITY No* Social Security Number is for record-keeping purposes only. 34 and 41 a 7 and a 8. EMPLOYEE INFORMATION NAME ADDRESS City State PHONE Zip SOCIAL SECURITY No* Social Security Number is for record-keeping purposes only. DATE OF INJURY PANEL No* CLAIM/CASE No* CLAIMS ADMINISTRATOR INFORMATION COMPANY APPOINTMENT INFORMATION DATE OF APPOINTMENT CALL TIME OF LOCATION OF APPOINTMENT CERTIFIED INTERPRETER REQUIRED LANGUAGE COPY TO EMPLOYEE and employee s attorney if known SIGNATURE OF QME QME NAME print/type ADDRESS AND PHONE Note to Claims Administrator The Administrative Director s regulation 10160 requires you to forward a completed DWC-AD form 101 DEU Request for Summary Rating Determination of Qualified Medical Evaluator s Report see 8 Cal* Code Regs.