Notice of Late QME Report (QME Form 116) – Free Template Download

Purpose of the QME Form 116

The Notice of Late QME Report has several purposes:

• Notifying the delay: It formally informs the injured worker, employer, and their legal representatives that the QME report is not yet submitted.
• Maintaining compliance: It also ensures that medical evaluations are completed within the deadlines set by regulatory boards to avoid delays in processing claims.
• Encouraging timely submission: It reminds the QMEs of their obligation to provide the report on time or to take necessary steps if an extension is needed.

Who receives the notice?

The QME Form 116 is sent to the following people involved in the worker’s compensation claim:

• Injured worker: To ensure they are informed about potential delays in their claim processing.
• Employer: To help them resolve claims on time.
• Insurance carrier: Who needs timely reports to manage their claims.
• Legal teams: To assist in delays or taking necessary actions

What should be done after receiving the notice?

Once the late QME report notice is issued, the following actions can be taken:

• Extension request: The QME can formally request for an extension to complete the report, providing a valid reason for the delay in submitting the report. The approval of the extension depends on compliance with the California Worker’s Compensation regulations.
• Replacement of QME: If the delay is not justified with a valid explanation or the extension request is denied, the parties may need to request a replacement of the QME from the Division of Worker’s Compensation (DWC).
• Resolving the dispute: If there is a disagreement regarding the late report, the issue may be forwarded to the worker’s compensation judge for resolution through a formal hearing.

Details included in the Notice

The Form 116 typically includes:

• Claim details: Injured worker’s name, case number, and claim administrator information.
• QME details: Name and contact information of the assigned QME.
• Deadline information: Original report submission deadline and the extent of the delay.
• Next steps: Instructions for requesting an extension or initiating replacement procedures.
• Download the Notice of Late QME Report Template

Download Your Free Doctor’s First Report of Injury Form

To ensure compliance and streamline the claims process, download our free Notice of Late QME Report (QME Form 116) template. This easy-to-use form helps notify all parties about delayed medical evaluations and outlines the necessary steps to resolve the issue efficiently.

Download now to stay compliant with California workers’ compensation requirements and manage claim timelines effectively.