QME Notice of Unavailability (Form 109) – Free Template Download | Free Download

The QME Notice of Unavailability (Form 109) is an essential form used in California workers' compensation cases to notify the Division of Workers' Compensation (DWC) Medical Unit when a Qualified Medical Evaluator (QME) will be temporarily unavailable to perform evaluations. This form ensures compliance with state regulations and helps avoid scheduling conflicts during the absence of the QME.

Purpose of the QME Form 109

The QME Form 109 is used to:

Inform the Medical director of the QME’s temporary unavailability for evaluations.

Prevent issues in scheduling QME evaluations by ensuring claimants and insurers are aware of the unavailability period.

Maintain regulatory compliance with the California Worker’s Compensation Board.

Who needs the Notice of Unavailability Form?

The QME Form 109 is used by:

Qualified Medical Evaluators (QMEs) in California who need to take a temporary break from their evaluation services.

Legal representatives or claims administrators, if needed, to manage ongoing workers' compensation cases efficiently.

QMEs must file Form 109 at least 30 days in advance of their planned unavailability to avoid penalties and ensure that no appointments are scheduled during their absence.

Information Included in QME Form 109

This QME Form typically includes:

Personal details: QME name, license number, and contact information.

Period of unavailability: Start and end dates of the absence.

Reason for absence: General description (e.g., medical leave, vacation, etc.).

Existing appointments: Any scheduled evaluations that might be affected.

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