DWC Posts Revised QME Form 105 and Instructions for Forms 105, 106 and 37 By Dept of Industrial Relations - November 13, 2013
The Division of Workers’ Compensation (DWC) has posted a revised version of QME Form 105 as well as helpful instructions for its completion. Parties are required to use the revised Form 105 beginning December 1, 2014. Form 105 is used to request a panel Qualified Medical Evaluator (QME) examination for an unrepresented employee. A Spanish-language version of the form and instructions for its use will be available soon.
In addition to the revised Form 105, instructions for the completion of QME Form 106 (used to request a panel QME for a represented employee) and QME Form 37 (used to request factual correction of an unrepresented panel QME report) have been posted.
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P.O. Box 420603 · San Francisco, CA · 94142-0603 · www.dir.ca.gov
Adjuster / Examiner Claims Examiner Santa Ana Unified School District Santa Ana, CA
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