Get Qme Appointment Notification Form

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. 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. The Administrative Director also requires that you serve this appointment notification form on the employee and the claims administrator or if none the employer or their attorneys in a represented case within five 5 business days after having scheduled the injured worker to be seen for a QME comprehensive medical evaluation* 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* INSURER or 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 CLAIMS ADMINISTRATOR/EMPLOYER and 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 DEU Form 101 Request for Summary Rating together with all medical reports and medical records prior to the scheduled examination with the QME* You must also provide the employee with a DEU Form 100 Employee s Disability Questionnaire prior to the examination* QME Form 110 rev* Mar* 2007 June 2008. 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. The Administrative Director also requires that you serve this appointment notification form on the employee and the claims administrator or if none the employer or their attorneys in a represented case within five 5 business days after having scheduled the injured worker to be seen for a QME comprehensive medical evaluation* EMPLOYEE INFORMATION NAME ADDRESS City State PHONE Zip SOCIAL SECURITY No* Social Security Number is for record-keeping purposes only. The Administrative Director also requires that you serve this appointment notification form on the employee and the claims administrator or if none the employer or their attorneys in a represented case within five 5 business days after having scheduled the injured worker to be seen for a QME comprehensive medical evaluation* 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* INSURER or 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 CLAIMS ADMINISTRATOR/EMPLOYER and 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 DEU Form 101 Request for Summary Rating together with all medical reports and medical records prior to the scheduled examination with the QME* You must also provide the employee with a DEU Form 100 Employee s Disability Questionnaire prior to the examination* QME Form 110 rev* Mar* 2007 June 2008.