Fillable Form 4: QUALIFIED MEDICAL EVALUATOR'S FINDINGS SUMMARY FORM (California)

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Form 4: QUALIFIED MEDICAL EVALUATOR'S FINDINGS SUMMARY FORM (California)

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The Form 4: QUALIFIED MEDICAL EVALUATOR'S FINDINGS SUMMARY FORM (California) form is 3 pages long and contains:

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________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
STATE OF CALIFORNIA
Division of Workers’ Compensation – Medical Unit
P.O. Box 71010, Oakland, CA 94612
(510) 286-3700 or (800) 794-6900
QUALIFIED MEDICAL EVALUATOR'S FINDINGS SUMMARY FORM
UNREPRESENTED INJURED EMPLOYEE CASES ONLY
EMPLOYEE
1. Employee Name (First, Middle, Last) 2. Social Sec. No. (Optional) 3. Date of Injury
4
. Street Address City Zip 5. Phone
CLAIMS ADMINISTRATOR (if none, enter Employer information)
6. Name
7. Street Address City Zip 8. Phone
EVENT DATES
9. Date of Appointment Call 10. Initial Examination Date 11. Date of Referral for Medical Testing/Consultation
12a. Date QME Report Served on all Parties 12b. Date(s) of all prior report(s) served by this QME?
DISPUTED MEDICAL ISSUES AND CONCLUSIONS
13. The following medical issues will be used to determine the injured employee’s eligibility for workers' compensation benefits.
(Check the appropriate box)
Pending or
Yes No Info. Not Sent
a. Has the condition reached permanent and stationary
status or maximum medical improvement?
b. Is there permanent impairment/disability?
c. Did work cause or contribute to the injury or illness?
d. If permanent disability exists, is
apportionment
warranted?
e. Is there a need for current or future medical care?
f. Can this employee now return to his/her usual job? Yes No
If yes:
i. Without restrictions
Yes No, If YES, Date: ________________
ii. With restrictions Yes No, If YES, Date: ________________
BASIS FOR CONCLUSIONS
(Check the appropriate box)
Pending or
Yes No Info. Not Sent
14. Are there subjective complaints?
15. Are there any abnormal physical or psychological
examination findings?
16. Are impairments described and measured using:
(For non-psyche injuries)
the AMA Guides?
(For psyche injuries) the GAF and 2005 PD Schedule?
QME Form 111 (rev. February 2009)
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CLEAR
________________________________________________________________________________________________________
Pending or
Yes No Info. Not Sent
17. If the AMA Guides are used, are percentages of impairment stated?
18. Are there any relevant diagnostic test
results (x-ray/laboratory)?
19. What are the diagnoses? (List) _________________________________________________________________________
20. Were medical records reviewed?
21. Were other physicians consulted?
22.
Are there any unresolved disputed issues beyond the scope of your licensure or clinical competence that
should be addressed by an evaluator in a different specialty?
23. If the answer to # 22 is yes, what disputed issue(s)
?_________________________________________________________
24. Based on the answer in # 23, what specialty (or specialties)?___________________________________________
QME
22. Signature:
___________________________________________________________Date:__________________________
23. Name:_____________________________________________________Specialty:_______________________________
24. Street Address:______________________________________City:___________________________Zip:_____________
25. Phone:_______________________________________ Cal. License No.:_______________________________________
Declaration of Service of Medical - Legal Report (Lab. Code § 4062.3(i))
I, ______________________________________________________________________________________, declare:
(Print Name)
1. I am over the age of 18 and I am not a party to this case.
2. My business address is :_________________________________________________________________________________________
3. On the date shown below, I served this QME Findings Summary Form with the original, or a true and correct copy of the original, comprehensive
medical-legal report, which is attached, on each of the persons or firms named below, by placing it in a sealed envelope, addressed to the person or
firm named below, and by:
A depositing the sealed envelope with the U. S. Postal Service with the postage fully prepaid.
B
placing the sealed envelope for collection and mailing following our ordinary business practices. I
am readily familiar with this business’s practice for collecting and processing correspondence for
mailing. On the same day that correspondence is placed for collection and mailing, it is deposited
in the ordinary course of business with the U. S. Postal Service in a sealed envelope with postage
fully prepaid.
C placing the sealed envelope for collection and overnight delivery at an office or a regularly utilized
drop box of the overnight
delivery carrier.
D placing the sealed envelope for pick up by a professional messenger service for service. (Messenger
must return t
o you a completed declaration of personal service.)
E personally delivering the sealed envelope to the person or firm named below at the address shown
below.
QME Form 111 (rev. February 2009)
click to sign
signature
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___________________________________________________
Means of service: Date: Addressee and Address:
(For each addressee,
Enter A – E as appropriate)
____________________ ________ _____________________________________________________________________
____________________ ________ _____________________________________________________________________
____________________ ________ _____________________________________________________________________
____________________ ________ _____________________________________________________________________
When report addresses PD:
____________________ ________ Disability Evaluation Unit, DWC,__________________________________________
I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
Date Signed: ____________________________________
(Signature of Declarant)
_______________________________________________
(Print Name)
INSTRUCTIONS FOR QME FORM 111
USE THIS FORM ONLY WHEN THE INJURED EMPLOYEE IS UNREPRESENTED
To the QME: You are required by Labor Code section 4062.3(i) to summarize the medical findings from your
comprehensive medical-legal evaluation on the form prescribed by the Administrative Director. Please complete
the form in its entirety.
Employee Information: Fill in the employee's full name, address, telephone number and date of injury.
Event Dates: Complete dates that patient called for an appointment, date of initial examination, date referred for
consultation(s), if any, and date(s) report(s) served on all parties. Supplying these dates is a legal requirement.
Disputed Medical Issues and Conclusions: Complete this section by checking appropriate box and stating what
page(s) or section of the medical legal report contain the narrative for details. If diagnostic or laboratory tests
have been ordered and the results or a medical records request is pending, check that box. If you cannot render
opinions because of pending information, please complete and serve the report to comply with the 30-day time
requirement and state what issues could not be evaluated.
Basis for Conclusions: Check appropriate box for each question on form. For diagnoses, please briefly
summarize
the diagnoses in lay terms where possible, except when you deem that not advisable in disputed
claims involving injury to the psyche. Also, list the name and specialty for other physicians who provided
information used in the medical legal report.
Need for Additional Evaluation in Another Specialty: Labor Code section 4062.3 directs each evaluator to
address all contested medical issues
arising from all injuries reported on one or more claim forms prior to the
evaluator’s initial evaluation. Each evaluator is expected to address permanent impairment consistent with the
AMA guides for the evaluator’s specialty, or for disputed injuries to the psyche consistent with the global
assessment of functioning (GAF) as directed in the 2005 Permanent Disability Schedule adopted by the
Administrative Director effective 1/1/2005. In the event there are contested medical issues outside of the scope
QME Form 111 (rev. February 2009)
click to sign
signature
click to edit
of your licensure or clinical competence that require evaluation by a physician in a different specialty, complete
the information required in questions 22 through 24, and serve a copy of your report on the Medical Unit of
DWC.
QME Signature: Remember under the Labor Code, all your reports must be signed under the penalty of perjury.
You are required to
serve the medical legal report and this form on the employee (unless the claim involves a
disputed injury to the psyche and section 36.5 of Title 8 of the California Code of Regulations applies and
provides for a different method of service), the claims administrator (if none, the employer) and whenever the
report finds permanent impairment and permanent disability, on the Disability Evaluation Unit (DEU) having
jurisdiction over the employee's area of residence.
Declaration of Service of Medical – Legal reports: Labor Code sections 139.2(j)(1)(A) and 4062.3 (i) and
section 38 of Title 8 of the California Code of Regulations require the
QME to serve the medical-legal report and
this form on the claims administrator, or if none the employer, and the injured worker (except when section 36.5
of Title 8 of the California Code of Regulations applies) within 30 days from the commencement of the
examination, unless certain conditions are met. Please complete the proof of service to show the date the report
was served on the parties and the Disability Evaluation Unit.
QME Form 111 (rev. February 2009)
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Form 4: QUALIFIED MEDICAL EVALUATOR'S FINDINGS SUMMARY FORM (California)

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Completed 23 August 2021

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