Fillable Form must be filed 30 days prior to (California)

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Form must be filed 30 days prior to (California)

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State of California
Division of Workers’ Compensation Medical Unit
P.O. Box 71010
Oakland, CA 94612
QME Notice of Unavailability
Form must be filed 30 days prior to date of unavailability
Complete both pages of this application to request unavailability. It is not an acceptable reason to request unavailability that a
QME does not intend to perform evaluations for unrepresented workers. A QME who is unavailable may not schedule or perform
QME evaluation examinations (initial or follow up) until the QME returns to active status. A QME may complete reports for
evaluation exams performed before becoming unavailable or supplemental reports. A QME who is unavailable for more than 90
calendar days during the calendar year without good cause may be denied reappointment. If this form is being filed less than 30
days before the QME is to become unavailable, attach a separate explanation of good cause for approving the late application.
Check the appropriate box to indicate that you will be unavailable for panel assignments for a period of 14 days to 90 days.
(MM/DD/YYYY)
(MM/DD/YYYY)
to
I will be unavailable only at the QME office location (s) listed below for all qualified medical
evaluation panel assignments from
I will be unavailable for all qualified medical evaluation panel assignments
from
Street Address
City Zip Code
Zip CodeCity
Street Address
Zip CodeCity
Street Address
Zip CodeCity
Street Address
QME Form 109 (rev. 9/2015)
QME first name (Required) (Print or type):
QME signature
Date
(MM/DD/YYYY)
to
(MM/DD/YYYY)
Zip CodeCity
Street Address
Zip CodeCity
Street Address
Zip CodeCity
Street Address
Zip CodeCity
Street Address
Page 1 of 2
Zip CodeCity
Street Address
Completion of this section is required.(Choose only one)
Zip CodeCity
Street Address
QME last name (Required) (Print or type):
Calif. License number
Reset Form
Print Form
Exam StatusAppointment Type
Panel number, if applicable
Injured Worker Name
Appointment date
(MM/DD/YYYY)
Section 33(c) of title 8 of the California Code of Regulations requires a QME to list all of the comprehensive medical/legal
evaluation examinations already scheduled during the time requested for unavailable status at the time the request is filed with the
medical unit. (Completion of this section is required)
QME Form 109 (rev. 9/2015)
Exam Status
Appointment Type
Panel number, if applicable
Injured Worker Name
Appointment date
(MM/DD/YYYY)
Exam StatusAppointment Type
Panel number, if applicable
Injured Worker Name
Appointment date
(MM/DD/YYYY)
Exam StatusAppointment Type
Panel number, if applicable
Injured Worker Name
Appointment date
(MM/DD/YYYY)
Exam StatusAppointment Type
Panel number, if applicable
Injured Worker Name
Appointment date
(MM/DD/YYYY)
Exam StatusAppointment Type
Panel number, if applicable
Injured Worker Name
Appointment date
(MM/DD/YYYY)
Exam StatusAppointment Type
Panel number, if applicable
Injured Worker Name
Appointment date
(MM/DD/YYYY)
Exam Status
Appointment Type
Panel number, if applicable
Injured Worker Name
Appointment date
(MM/DD/YYYY)
Exam Status
Appointment Type
Panel number, if applicable
Injured Worker Name
Appointment date
(MM/DD/YYYY)
Exam StatusAppointment Type
Panel number, if applicable
Injured Worker Name
Appointment date
(MM/DD/YYYY)
Exam StatusAppointment Type
Panel number, if applicable
Injured Worker Name
Appointment date
(MM/DD/YYYY)
Exam StatusAppointment Type
Panel number, if applicable
Injured Worker Name
Appointment date
(MM/DD/YYYY)
Exam Status
Appointment Type
Panel number, if applicable
Injured Worker Name
Appointment date
(MM/DD/YYYY)
Exam Status
Appointment Type
Panel number, if applicable
Injured Worker Name
Appointment date
(MM/DD/YYYY)
Page 2 of 2
Calif. License number
I have no examinations scheduled during the period I have requested unavailability.
Date of the request
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Form must be filed 30 days prior to (California)

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Completed 18 March 2021

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