Download Free QME Form 106 for Easy QME Panel Requests | Free Download

The Request for QME Panel Under Labor Code § 4062.2 (QME Form 106) is an important document used in California workers' compensation cases when an injured worker is represented by an attorney. This form allows either party to request a panel of three Qualified Medical Evaluators (QMEs) to resolve disputed medical issues, as required by California Labor Code section 4062.2. It ensures an impartial evaluation when the parties involved cannot agree on a single Agreed Medical Evaluator (AME).

Why to Use the QME Form 106?

The QME Form 106 is necessary when:

A medical dispute arises regarding the extent of the worker’s injury.

Both parties have tried but failed to agree on an Agreed Medical Evaluator (AME) within the required time frame.

A formal evaluation is needed to determine the worker's medical condition for workers' compensation claims.

What information does the form include?

The QME Panel Request Form 106 contains essential details such as:

Injured worker’s information: Name, claim number, and contact details.

Medical dispute details: Specific medical issues on argument.

Preferred medical specialty: The desired specialty of the QME panel.

Parties involved: Information about the injured worker, employer, and legal representatives.

How to Submit the QME Form 106

To submit the QME Panel Request Form 106, follow these steps:

Complete all required fields, ensuring accuracy in worker and claim details.

Select the medical specialty that applies to the disputed issue.

Sign and date the form, confirming agreement to the panel process.

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