Download Free QME Form 106 for Easy QME Panel Requests
The Request for QME Panel Under Labor Code § 4062.2 (QME Form 106) is an important document used in California workers’ compensation cases when an injured worker is represented by an attorney. This form allows either party to request a panel of three Qualified Medical Evaluators (QMEs) to resolve disputed medical issues, as required by California Labor Code section 4062.2. It ensures an impartial evaluation when the involved parties cannot agree on a single Agreed Medical Evaluator (AME).
Why to Use the QME Form 106?
The QME Form 106 is necessary when:
- A medical dispute arises regarding the extent of the worker’s injury.
- Both parties have tried but failed to agree on an Agreed Medical Evaluator (AME) within the required time frame.
- A formal evaluation is needed to determine the worker’s medical condition for workers’ compensation claims.
Who Can Use This Form?
Only the following parties involved in a California workers’ compensation case can submit the QME Form 106:
- Injured employees who are represented by an attorney.
- Employers or their claims administrators, who manage workers’ compensation claims.
What information does the form include?
- Injured worker’s information: Name, claim number, and contact details.
- Medical dispute details: Specific medical issues on argument.
- Preferred medical specialty: The desired specialty of the QME panel.
- Parties involved: Information about the injured worker, employer, and legal representatives.
How to Submit the QME Form 106
To submit the QME Panel Request Form 106, follow these steps:
- Complete all required fields, ensuring accuracy in worker and claim details.
- Select the medical specialty that applies to the disputed issue.
- Sign and date the form, confirming agreement to the panel process.
Ensure a fair and legal resolution of disputed medical issues by downloading our free QME Form 106 template today. Our easy-to-use template ensures compliance with California workers’ compensation regulations and streamlines the QME panel request process.
Download now and take control of your claims process!
Template Categories
California
General
How to Use the QME Form 106 Template
Getting started with the QME Fee Assessment Form 103 is easy:
-
- Click the download button on this page.
- Enter your email address to receive the form.
- Download and tailor it with your case specific details.
- Submit the completed form to the appropriate DWC office for processing.
Get your free QME Form 106 template today and simplify your workers’ compensation dispute resolution!
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