Free QME Form 111 Template – Download Now for Unrepresented Injured Employee Cases
The Qualified Medical Evaluator’s Findings Summary Form (Form 111) is used in California workers’ compensation cases where the injured worker does not have an attorney. This form provides a clear and concise summary of the QME’s medical evaluation, helping the claims administrator understand the case without reviewing a full medical report.
Why Use QME Form 111?
This form is designed to:
- Summarize the QME’s findings in a simple, easy-to-read format.
- Provide key medical details about the injury, disability rating, and treatment recommendations.
- Ensure claims administrators receive essential medical information without needing the full medical-legal report.
Who Completes This Form?
The Qualified Medical Evaluator (QME) completes Form 111 after examining the injured worker. It is only used when the injured worker does not have legal representation.
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.
What Information Is Included?
- Injured worker’s details
- Date of injury and medical evaluation
- Disputed medical issues
- QME’s findings, including diagnosis and disability rating
- Treatment recommendations and next steps
Download the Free QME Form 111 Template
Make the claims process smoother with a clear medical summary from the Qualified Medical Evaluator. Download the free Form 111 template now to ensure accurate and efficient reporting!
Template Categories
California
General
How to Use the Template
Getting started with the QME Form 111 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.
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