QME Notice of Unavailability (Form 109) – Free Template Download
The QME Notice of Unavailability (Form 109) is an essential form used in California workers’ compensation cases to notify the Division of Workers’ Compensation (DWC) Medical Unit when a Qualified Medical Evaluator (QME) will be temporarily unavailable to perform evaluations. This form ensures compliance with state regulations and helps avoid scheduling conflicts during the absence of the QME.
Purpose of the QME Form 109
The QME Form 109 is used to:
- Inform the Medical director of the QME’s temporary unavailability for evaluations.
- Prevent issues in scheduling QME evaluations by ensuring claimants and insurers are aware of the unavailability period.
- Maintain regulatory compliance with the California Worker’s Compensation Board.
Who needs the Notice of Unavailability Form?
The QME Form 109 is used by:
- Qualified Medical Evaluators (QMEs) in California who need to take a temporary break from their evaluation services.
- Legal representatives or claims administrators, if needed, to manage ongoing workers’ compensation cases efficiently.
QMEs must file Form 109 at least 30 days in advance of their planned unavailability to avoid penalties and ensure that no appointments are scheduled during their absence.
Information Included in QME Form 109
This QME Form typically includes:
- Personal details: QME name, license number, and contact information.
- Period of unavailability: Start and end dates of the absence.
- Reason for absence: General description (e.g., medical leave, vacation, etc.).
- Existing appointments: Any scheduled evaluations that might be affected.
Download the Free QME Notice of Unavailability Template
Stay compliant with California regulations by downloading our free QME Form 109 template today. Simply fill out the form and submit it to the Medical Unit on time to avoid legal repercussions.
Download now to ensure a smooth leave process without disruptions!
Template Categories
California
General
How to Use the Template
- Tap the download button and type your email address.
- Get the form in your inbox instantly.
- Fill out the form with the necessary claim and QME information.
- Submit the completed notice to the appropriate parties.
Ensure timely claim processing and avoid unnecessary delays by using the Notice of Unavailability template today!
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