State of California
Division of Workers' Compensation - Medical Unit
Additional Panel Request-8 Cal. Code of Regulations section 31.7
(Please print or type)
EAMS number
(Required if a case is filed)
Joint request
Applicant's Attorney/Injured Worker
Defense Attorney/Claims Administrator
Requesting Party (Required)
Employee last name (Required)
Claim number (Required)
Original panel number (Required)
Employee first name (Required)
A written agreement between the parties in a represented case.
(Please attach a signed joint letter or jointly sign the bottom of this form)
The acupuncturist QME selected advised the parties that disability is in issue and a QME in a different specialty is
(Please attach copy of the letter from the AME/QME.)
Reason for the additional panel request (Required)
Specialty to be issued
Specialty to be issued
Specialty to be issued
Indicate the specialties you are requesting. Each specialty request must be
justified by the reason listed above.
Signature of Requestor:
Name of Requestor (Required)
Date of Request:
Requestor Address (Required)
Zip Code (Required)State (Required)
Zip Code
Signature of Requestor:
Requestor Address
Name of Requestor
QME form 31.7(10/2013)
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:
, I served this Additional Panel Request 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.
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.
placing the sealed envelope for collection and overnight delivery at an office or a regularly utilized drop
box of the overnight delivery carrier.
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
Street Address
Method of
Street Address
Zip Code
Person or firm served
Method of
Street Address
Zip Code
Person or firm served
Method of
Zip Code
Street Address
Person or firm served
Method of
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.
QME form 31.7(10/2013)
MD/DO Specialty Codes NON-MD/DO Specialty Codes
MAI Allergy & Immunology ACA Acupuncture
MDE Dermatology
DCH Chiropractic
MEM Emergency Medicine
DEN Dentistry
MFP Family Practice
OPT Optometry
MPM General Preventive Medicine
POD Podiatry
MHH Surgery - Hand
PSY Psychology
MMM Internal Medicine
PSN Psychology - Clinical Neuropsychology
MMV Internal Medicine - Cardiovascular Disease
Internal Medicine – Endocrinology Diabetes &
MMG Internal Medicine - Gastroenterology
MMH Internal Medicine - Hematology
MMI Internal Medicine - Infectious Disease
MMO Internal Medicine - Medical Oncology
MMN Internal Medicine - Nephrology
MMP Internal Medicine - Pulmonary Disease
MMR Internal Medicine - Rheumatology
MNB Spine
MPN Neurology
MNS Neurological Surgery (other than Spine)
MOG Obstetrics & Gynecology
MPO Occupational Medicine
MOS Orthopaedic Surgery (other than Spine or Hand)
MTO Otolaryngology
MPA Pain Medicine
MHA Pathology
MPR Physical Medicine & Rehabilitation
MPD Psychiatry (other than Pain Medicine)
MSY Surgery (other than Spine or Hand)
MSG Surgery - General Vascular
MTS Thoracic Surgery
MTT Toxicology
MUU Urology
QME Specialty Codes
Do Not file this page with your additional panel request!
QME form 31.7(10/2013)