Fillable State of California Division of Workers' Compensation-Medical Unit (California)

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State of California Division of Workers' Compensation-Medical Unit (California)

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The State of California Division of Workers' Compensation-Medical Unit (California) form is 2 pages long and contains:

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Please complete this form in its entirety. The Administrative Director requires that you serve this appointment notification form on the
employee and the claims administrator, or, if none the employer, and their attorneys in a represented case, if known, within five (5) business
days after having scheduled the injured worker to be seen for a QME comprehensive medical-legal evaluation. You may not cancel the
appointment less than six (6) calendar days prior to the appointment date, except for good cause (See, 8 Cal. Code Regs. §34). If you
reschedule an appointment, review regulation 34 and the ethical rules in regulation 41 (See, 8 Cal Code Regs. §§ 34, 41(a) (7) and (a) (8)).
State of California
Division of Workers' Compensation-Medical Unit
QME Appointment Notification Form
Employee Information (Completion of this section is required)
Employee Name
Employee Street Address Employee City
State
Zip Code
Phone Number
Date of Injury Panel Number Claim or Case Number
Employer Information
Zip CodeStateEmployer CityEmployer Street Address
Employer Name
Claims Administrator Information (Completion of this section is required)
Zip CodeStateClaims Administrator City Claims Administrator Street Address
Claims Administrator Name (Insert the name of the person handling the claim)
Claims Administrator Company (Insert the name of the company handling the claim)
Date of appointment call:
Appointment Information (Completion of this section is required)
Date of Appointment:
Examination address
Time of appointment:
If an interpreter is required, indicate language:
QME Name:
Zip Code
QME City
QME Street Address
Note to Claims Administrator: The Administrative Director's regulation 10160 requires you to forward a completed, DWC-AD form
101(DEU) (Request for Summary Rating Determination of Qualified Medical Evaluator's Report) (see, 8 Cal. Code Regs. §§ 10160
and 10161) together with all medical reports and medical records prior to the scheduled examination with the QME. You must also
provide the employee with a DWC-AD form 100 (DEU) (Employee's Disability Questionnaire)(See, 8 Cal. Code Regs. §§ 10160 and
10161) prior to the examination.
QME Form 110 (rev. 10/2013)
Date Signed: Signature of the QME:
Is a certified interpreter required? Yes No
Page 1 of 2
Examination City:
Zip Code
Phone Number
Records should be sent to the following address:
Zip Code
City:Street address or P.O. Box
State
Print Form
Reset Form
Declaration of Service
I declare that I am a resident of or employed in the county where the mailing took place. I am over the age of
eighteen years and I am not a party to this case, my business or residence address is:
On
, I served this QME Appointment Notification Form, the original, or a true and correct copy
of the original, 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 to 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.
Person or firm served
Zip Code
State
City
Street Address
Method of
Service
Street Address
Zip Code
State
City
Person or firm served
Method of
Service
Street Address
Zip Code
State
City
Person or firm served
Method of
Service
City
State
Zip Code:
Street Address
Person or firm served
Method of
Service
I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
Signature _____________________________________________
Type or print name
, California.
atDate:
QME Form 110 (rev. 10/2013)
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State of California Division of Workers' Compensation-Medical Unit (California)

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Completed 18 March 2021

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