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Get Qme Request Represented Fillable Form

Fense Attorney /Claims Administrator Reason QME panel is being requested (Read attachment, How to Request a QME') (Check one box only): 4060 (compensability exam) 4061 (permanent impairment or disability dispute) 4062 Injured employee only (medical treatment determination, UR dispute or other 4062 reason ) 4062 Claims administrator only (non treatment medical determination or non-UR reason under 4062) 4061 and 4062 dispute (medical treatment and permanent impairment or disabil.

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