Download QME Form 105 for Free – Complete Your QME Panel Request

When to Use the QME Panel Request Form 105

You should use the Request for Qualified Medical Evaluator Panel Form 105 when:

• The injured worker is not represented by an attorney.
• There is a disagreement regarding the treating physician’s opinion.
• A determination is needed to establish if the injury is work-related.
• There is an objection to the primary treating physician’s assessment of the injury.

Who Can Use This Form?

The QME Panel Request Form 105 can be used by:

• Injured workers who are not represented by an attorney, to ensure an independent medical evaluation.
• Claims administrators, who manage workers’ compensation claims and require an objective medical opinion.

How to Complete the Form

Filling out the Request for QME Panel Form 105 is a simple process:

• Complete all required fields, including personal and claim details.
• Select the preferred medical specialty for the QME evaluation.
• Date and sign the form, ensuring all details are accurate.
• Submit the form to the appropriate address based on your role in the claim.

Download Your Free QME Panel Request Form 105

Ensure a fair and impartial medical review by downloading our free Request for Qualified Medical Evaluator Panel Form 105 template today. This template makes it easy to request a QME panel and resolve disputes in workers’ compensation claims.

Download now and take the next step in your claims process!