Request for Factual Correction of an Unrepresented Panel QME Report (Form 37)
The Request for Factual Correction of an Unrepresented Panel QME Report (QME Form 37) is an essential document in California workers’ compensation cases. It allows an unrepresented injured worker to formally request corrections to factual errors in a Qualified Medical Evaluator (QME) report, ensuring accuracy in their medical evaluation. This form is used strictly to correct verifiable factual mistakes and not to dispute medical opinions.
Purpose of QME Form 37
The QME Form 37 serves the following key purposes:
- Ensures accuracy: Allows injured workers to correct errors in their QME report that can be verified with existing medical records.
- Improves claim fairness: Helps prevent factual inaccuracies from affecting workers’ compensation decisions.
- Maintains transparency: Gives unrepresented workers a formal process to address factual discrepancies.
Who Can Use QME Form 37?
Only injured workers who are NOT represented by an attorney are eligible to submit this form. If the worker has legal representation, their attorney must follow a different procedure to dispute inaccuracies in the QME report.
When Should QME Form 37 Be Submitted?
The Request for Factual Correction (QME Form 37) must be submitted within a specific timeframe after receiving the QME report. Workers should check their notification letter to confirm the deadline for submitting corrections.
How to Use QME Form 37
- Review the QME report for factual errors that can be verified using submitted medical records.
- Complete the form with details of the incorrect information and the requested correction.
- Submit the form to the QME within the required timeframe.
- Wait for the QME’s response—the evaluator has a set time to review and decide whether corrections are necessary.
What Information Can Be Corrected?
Corrections are limited to verifiable factual errors in the QME report, such as:
- Incorrect dates of treatment or injury.
- Misreported job duties or medical history.
- Errors in listed medications or past treatments.
- Mistakes in identifying pre-existing conditions.
Medical opinions or conclusions made by the QME cannot be challenged using this form.
Why Is This Form Important?
A factual error in a QME report can impact the outcome of a workers’ compensation case. Submitting QME Form 37 ensures that decisions affecting benefits and treatment are based on accurate information.
Download the QME Form 37 Template for Free
Get your free QME Form 37 template to correct factual errors in your unrepresented panel QME report and protect your workers’ compensation rights.
Download now and ensure accuracy in your medical-legal evaluation!
Template Categories
California
General
How to Use the QME Form 37
- Tap on the download button on the page.
- Enter your email address to get the form instantly in your inbox.
- Review and furnish the form with necessary details.
- Submit the form to the QME within the required timeframe.
Download your QME Form 37 template today to request factual corrections in your panel QME report!
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