California Workers' Compensation Institute

QME Regulations

Optional Replacement Panel Request QME Form 31.5

Optional Additional Panel Request QME Form 31.7

Filed with Secretary of State (Effective date Feb. 17, 2009)

1/23/2009

Adopted Regulations
Adopted Regulations - clean copy
DWC Newsline 08-09
Final Statement of Reasons
Informative Digest Update
QME Form 100 Application for QME appointment
QME Form 102 Registration for QME competency examination
QME Form 103 QME fee assessment form
QME Form 104 QME Reappointment application
QME Form 105 Request For QME panel with attachment - unrepresented
QME Form 106 Request For QME panel with attachment - represented
QME Form 107 QME panel selection
QME Form 108 QME panel selection instruction form (injured worker information)
QME Form 109 QME notice of unavailability
QME Form 110 QME appointment notification form
QME Form 111 QME findings summary form
QME Form 112 QME/AME report time frame extension request
QME Form 113 Notice of time extension denial
QME Form 116 Notice of late QME/AME report - no extension requested
QME Form 117 QME course evaluation
QME Form 118 Application for education provider accreditation/re-accreditation
QME Form 119 Faculty disclosure of commercial interest
QME Form 120 Voluntary directive for alternate service of psych ML report
QME Form 121 Declaration regarding protection of mental health record
QME Form 122 AME/QME declaration of ML report service
QME Form 123 QME/AME conflict of interest disclosure form & objection/waiver
QME Form 124 QME disclosure of specified financial interests

Submitted to OAL

11/26/2008

Final Regulations
Final Statement of Reasons
QME Form 100 Application for QME appointment
QME Form 102 Registration for QME competency examination
QME Form 103 QME fee assessment form
QME Form 104 QME Reappointment application
QME Form 105 Attachment
QME Form 105 Request For QME panel - unrepresented
QME Form 106 Attachment
QME Form 106 Request For QME panel - represented
QME Form 107 QME panel selection
QME Form 108 QME panel selection instruction form (injured worker information)
QME Form 109 QME notice of unavailability
QME Form 110 QME appointment notification form
QME Form 111 QME findings summary form
QME Form 112 QME/AME report time frame extension request
QME Form 113 Notice of time extension denial
QME Form 116 Notice of late QME/AME report - no extension requested
QME Form 117 QME course evaluation
QME Form 118 Application for education provider accreditation/re-accreditation
QME Form 119 Faculty disclosure of commercial interest
QME Form 120 Voluntary directive for alternate service of psych ML report
QME Form 121 Protection of mental health record declaration
QME Form 122 AME/QME declaration of ML report service
QME Form 123 QME/AME conflict of interest disclosure form & objection/waiver
QME Form 124 QME disclosure of specified financial interests
The 1st 15 day comment chart
The 2nd 15 day comment chart
The 45 day public hearing comment chart

Extended 2nd 15-day Comment Period

11/06/2008

Amended Notice of Modifications
Amended Proposed Regulations
CWCI Comment
Deleted QME Form 105 Request For QME panel under Labor Code Section 4062.1 - unrepresented and attachment to form 105
Deleted QME Form 106 Request For QME panel under Labor Code Section 4062.2 - unrepresented and attachment to form 106
QME Form 105 Request For QME panel under Labor Code Section 4062.1 - unrepresented and attachment to form 105
QME Form 106 Request For QME panel under Labor Code Section 4062.2 - represented and attachment to form 106

2nd 15-day Comment Period

10/30/2008

DWC Newsline 57-08
Notice of Modifications
Proposed Regulations
QME Form 105 Request For QME panel under Labor Code Section 4062.1 - unrepresented and - attachment to form 105
QME Form 106 Request For QME panel under Labor Code Section 4062.2 - represented and - attachment to form 106
QME Form 107 QME panel selection
QME Form 108 QME panel selection instruction form (injured worker information)
QME Form 110 QME appointment notification form
QME Form 111 Qualified or agreed medical evaluator findings summary form
QME Form 112 QME/AME report time frame extension request
QME Form 113 Notice of denial of request for time extension
QME Form 116 Notice of late QME/AME report - no extension requested
QME Form 120 Voluntary directive for alternate service of medical-legal evaluation report on disputed injury to psyche
QME Form 121 Declaration regarding protection of mental health record
QME Form 122 AME or QME declaration of service of Medical - legal report
QME Form 125 Authorization for release of medical information

1st 15 Day Comment Period

7/10/2008

CWCI Comment
DWC Newsline 38-08
Notice of Modification
Proposed Regulations
QME Form 100 Application for appointment as qualified medical evaluator
QME Form 102 Registration for QME competency examination
QME Form 103 QME fee assessment form
QME Form 104 Reappointment application as qualified medical evaluator
QME Form 105 Request For QME panel under Labor Code Section 4062.1 - unrepresented and - attachment to form 105
QME Form 106 Request For QME panel under Labor Code Section 4062.2 - represented and - attachment to form 106
QME Form 107 QME panel selection
QME Form 108 QME panel selection instruction form (injured worker information)
QME Form 109 QME notice of unavailability
QME Form 110 QME appointment notification form
QME Form 111 Qualified or agreed medical evaluator findings summary form
QME Form 112 QME/AME report time frame extension request
QME Form 113 Notice of denial of request for time extension
QME Form 116 Notice of late QME/AME report - no extension requested
QME Form 117 QME course evaluation
QME Form 118 Application for accreditation or re-accreditation as education provider
QME Form 119 Faculty disclosure of commercial interest
QME Form 120 Voluntary directive for alternate service of medical-legal evaluation report on disputed injury to psyche
QME Form 121 Declaration regarding protection of mental health record
QME Form 122 AME or QME declaration of service of Medical - Legal report
QME Form 123 QME or AME conflict of interest disclosure form and objection or waiver
QME Form 124 QME disclosure of specified financial interests
Replaced QME Form 105 Request For QME panel under Labor Code Section 4062.1 - unrepresented and - attachment to form 105
Replaced QME Form 106 Request For QME panel under Labor Code Section 4062.2 - represented and - attachment to form 106

45-day Public Testimony Period

1/17/2008

CWCI written testimony
Initial Statement of Reasons
Notice of Proposed Rulemaking
Proposed regulations
QME Form 100 replacement application for appointment as qualified medical evaluator
QME Form 102 replacement registration for QME competency examination
QME Form 103 replacement QME fee assessment form
QME Form 104 replacement reappointment application as qualified medical evaluator
QME Form 105 replacement request For QME panel under Labor Code Section 4062.1 - unrepresented and - attachment to form 105
QME Form 106 replacement request For QME panel under Labor Code Section 4062.2 - represented and - attachment to form 106
QME Form 107 replacement QME panel selection
QME Form 108 replacement QME panel selection instruction form (injured worker information)
QME Form 109 replacement QME notice of unavailability
QME Form 110 replacement QME appointment notification form
QME Form 111 replacement qualified or agreed medical evaluator findings summary form
QME Form 112 replacement QME/AME report time frame extension request
QME Form 113 replacement notice of denial of request for time extension
QME Form 116 replacement notice of late QME/AME report - no extension requested
QME Form 117 replacement QME course evaluation
QME Form 118 replacement application for accreditation or re-accreditation as education provider
QME Form 119 replacement faculty disclosure of commercial interest
QME Form 120 replacement voluntary directive for alternate service of medical-legal evaluation report on disputed injury to psyche
QME Form 123 replacement QME or AME conflict of interest disclosure form and objection or waiver
QME Form 124 replacement QME disclosure of specified financial interests
Transcript of public hearing testimony - Los Angeles
Transcript of public hearing testimony - Oakland

2nd Forum Comments

4/13/2007

CWCI Comment
Draft Regulation
QME Form 100 Application for appointment as qualified medical evaluator
QME Form 102 Registration for QME Competency Examination
QME Form 103 Fee Assessment
QME Form 104 Reappointment Application As Qualified Medical Evaluator
QME Form 105 Request for QME Panel - Unrepresented, and Attachment to 105 How to Request a QME if You Do Not Have a Lawyer
QME Form 106 Request for QME Panel - Represented, and Attachment to 106 How to Request a QME in a Represented Case
QME Form 107 QME Panel Selection Form
QME Form 108 QME Panel Selection Instruction Form
QME Form 109 QME Notice Of Unavailability
QME Form 110 QME Appointment Notification Form
QME Form 111 Qualified or Agreed Medical Evaluator Findings Summary Form
QME Form 112 QME/AME Report Time Frame Extension Request Form
QME Form 113 Notice of Denial of Request for Time Extension Form
QME Form 116 Notice of Late QME/AME Report - No Extension Requested
QME Form 117 QME Course Evaluation Form
QME Form 118 Application For Accreditation Or Re-Accreditation As Education Provider
QME Form 119 Faculty Disclosure Of Commercial Interest
QME Form 120 Voluntary Directive For Alternate Service Of Medical-Legal Evaluation Report On Disputed Injury To Psyche (Unrepresented Employees Only)
QME Form 121 QME Request To Be Granted Inactive Status
QME Form 122 QME Request To Be Returned To Active Status

1st Forum Comments

3/22/2005

CWCI Comment