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(continued)
Professional practice specialty code: (______)
Professional practice specialty code: (______)
PROCEED TO BLOCK 4
________________________________________________________________
BLOCK 5 (FOR ALL APPLICANTS)
INITIAL
EACH BOX
AFFIRMATIONS Initialing each box affirms that you have read and agree
to each of the statments.
A. License Statues
My license to practice is currently active and unrestricted. I ( )
certify that I will notify the IMC of any of the following events:
a) change in my license status; b) any past or future conviction
related to the conduct of my practice or for any crime of moral
turpitude; and c) upon being placed on probation by my licensing
board or by any court-ordered probation. I understand that in suce
cases I am subject to disciplinary action by the IMC.
B. Probationary Status
I certify that I am not currently on probation with my licensing ( )
board nor on any court-orderd probation. I certify that I have not
committed a misdemeanor or felony related to my practice. I further
cerify that my licensing board has not taken anu action against me
and my license to practice is unrestricted. (Do not initial if your
statement is untrue; attach explanation on separate piece of paper.
I understand that in such cases I am subject to disceplinary action
by the IMC.)
C. Financial Interest
I have read and understand Labor Code Sections 139.3 and 139.31. I ( )
agree that I shall abide by all their provisions. I will not refer
patients to facilities in which I or my family members have a
financial interest, except a permitted by law. I agree I shall not
offer, deliver, recieve or accept any rebate, refund, commission,
preference, patronage, dividend, discount or other consideration,
whether in the form money or otherwise, as compensation or
inducement for any referred evaluation or consultation. I agree not
to solicit to provide medical treatment to an injured employee for
any injury for which I have done a QME evaluation. I have not
perfomed a QME evaluation while not certified by the IMC as a QME.
D. Continuing Education Courses
List the continuning education courses you have completed within the
last 24 months:
Name of Provider Name of Course Date(s) Number of Credits
---------------- -------------- ------- -----------------
---------------- -------------- ------- -----------------
---------------- -------------- ------- -----------------
---------------- -------------- ------- -----------------
________________________________________________________________
VERIFICATION
I have used all reasonable diligence in preparing and completing this application. I have reviewed this completed application and to the best of my knowledge the information contained herein and in the attached supporting documentation is true, correct and complete. Failure to provide truthful information shall result in denial of applicant's reappointment and/or discipinary procedures. I declare under penalty or perjury under the State of California that the foregoing is true and correct.
___________ ______ _______________________
Executed on (MM/DD/YY) at County CA Applicant's Signature
IMC FORM 104 Rev. 8/30/01
A PUBLIC DOCUMENT
PRIVACY NOTICE - The Information Practices Act of 1977 and the Federal Privacy Act require the Industrial Medical Council (IMC) to provide the following notice to individuals who are asked by a governmental entity to supply information for appointment as a Qualified Medical Evaluator (QME).
The principal purpose for requesting information from QMEs is to administer the QME program within the California workers' compensation system. Additional information may be requested if your application is denied and/or a disciplinary action is taken.
The California Labor Code requires every QME physician to meet certain statutory requirements. Physicians are required by the Labor Code to provide: name; business address/addresses; professional education; training; license number; year entered practice and other requirements deemed necessary by the IMC. It is mandatory to furnish all the appropriate information requested by the IMC. Failure to provide all of the requested information may result in the denial of the application.
As authorized by law, information furnished on this form may be given to: you, upon request; the public, pursuant to the Public Records Act; a governmental entity, when required by state or federal law; to any person, pursuant to a subpoena or court order or pursuant to any other exception in Civil Code s 1798.24.
An individual has a right of access to records containing his/her personal information that are maintained by the IMC. An individual may also amend, correct, or dispute information in such personal records (Civil Code s 1798.34-1798.37).
Requests should be sent to:
The Industrial Medical Council
P.O. BOX 8888
SAN FRANCISCO, CA 94128-8888
(650) 737-2700
www.dir.ca.gov
You may request a copy of the IMC policy and procedures for inspection of records at the above address. Copies of the procedures and all records are twenty-five cents ($0.25) per page, payable in advance. (Civil Code s 1798.33). IMC Form 104 Rev. 8/30/01
For Use on the QME Reappointment Application Form
MD/DO Specialty Codes Non-MD/DO Specialty Codes
MAI Allergy and Immunology *denotes a doctor of chiropractic
MAA Anesthesiology who has completed a chiropractic
MRS Colon & Rectal Surgery post-graduate specialty program
MDE Dermatology
MEM Emergency Medicine ACA Acupuncture
MFP Family Practice - MD DCH Chiropractic -
OFP Family Practice - DO DCN Chiropractic-Neurology*
OFM Family Practice - DO - DCO Chiropractic
Including Osteopathic -Orthopaedic*
Manipulation
MPM General Preventive Medicine DCR Chiropractic - Radiology*
MOH Hand-Orthopaedic Surgery DCS Chiropractic - Sports
Medicine*
MPH Hand-Plastic Surgery DCT Chiropractic -
Rehabilitation*
MSH Hand-Surgery DEN Dentistry
MMM Internal Medicine OPT Optometry
MMV Internal Medicine- POD Podiatry
Cardiovascular Disease PSY Psychology
MME Internal Medicine-Endocrinology PSN Psychology-Clinical
Diabetes and Metabolism Neuropsychology
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
MOQ Medicine - Otherwise Qualified
MPB Neurological Surgery-Including Back
MPN Neurology
MNS Neurological Surgery
MNM Nuclear Medicine
MOG Obstetrics and Gynecology
MPO Occupational Medicine
MOP Ophthalmology
MOS Orthopaedic Surgery
MOB Orthopaedic Surgery-
Including Back
MTO Otolaryngology
MAP Pain Management-Anesthesiology
MPP Pain Management-Pain Medicine
MHA Pathology
MEP Pediatrics
MPR Physical Medicine & Rehabilitation
MPS Plastic Surgery
MPD Psychiatry
MRY Radiology
MSY Surgery
MSG Surgery-General Vascular
MTS Thoracic Surgery
MPT Toxicology-Occupational Medicine
MET Toxicology-Emergency Medicine
MUU Urology
Attachment to Form 104
Rev. 8/30/01
s 105. The Request for Qualified Medical Evaluator Instruction Form.
STATE OF CALIFORNIA GRAY DAVIS, GOVERNOR
----------------------------------------------------------------
DEPARTMENT OF INDUSTRIAL RELATIONS
INDUSTRIAL MEDICAL COUNCIL ADDRESS REPLY TO:
395 OYSTER POINT BLVD., STE. 102 P.O. Box 8888
SOUTH SAN FRANCISCO, CA 94080 San Francisco, CA 94128-8888
TEL: (650) 737-2700 (800) 794-6900 Fax: (650) 737-2911
HOW TO REQUEST A QUALIFIED MEDICAL EVALUATOR
IF YOU DO NOT HAVE A LAWYER
Since you do not have a lawyer, you may ask the Industrial Medical Council for help in getting a Qualified Medical Evaluator (QME). The QME will look at your injury and answer medical questions about it.
To ask for a QME, please fill out the attached form and return immediately. You may ask for help from your treating doctor to determine the specialty appropriate for your injury. If the request form is incomplete or improperly completed, the form will be returned to you to correct the problem.
After our office processes your request, you will receive, in the mail, a list of three QMEs. These QMEs are selected at random and should have an office close to you. Only you may select the specialty of the QME who performs the evaluation.
You must make your appointment with one of the QMEs on the list. If the QME cannot make an appointment for an evaluation within 60 days of your call, your may either wait to see that QME of your choice or you may call us to get a replacement QME for your list. After completing the evaluation, the QME must send you a report within:
(a) 30 days of your appointment - if date of injury is on or after 1/1/94 or,
(b) 45 days of your appointment - if date of injury is between 1/1/91 and 12/31/93.
Please call the Industrial Medical Council at 1-800-794-6900, or the Information and Assistance officer from the Division of Workers' Compensation at 1-800-736-7401, if you have any questions relating to your workers' compensation claim.
Attachment to: IMC Form 106
IMC Form 105 Rev. 3/01/00
s 106. The Request for Qualified Medical Evaluator Form.
For Use with the QME Panel Request Form
[Note: The following TABLE/FORM is too wide to be displayed on one screen.
You must print it for a meaningful review of its contents. The table has been
divided into multiple pieces with each piece containing information to help you
assemble a printout of the table. The information for each piece includes: (1)
a three line message preceding the tabular data showing by line # and
character # the position of the upper left-hand corner of the piece and the
position of the piece within the entire table; and (2) a numeric scale
following the tabular data displaying the character positions.]
*******************************************************************************
******** This is piece 1. -- It begins at character 1 of table line 1. ********
*******************************************************************************
MAI Allergy and Immunology
MAA Anesthesiology
MRS Colon & Rectal Surgery
MDE
MEM Emergency Medicine
MFP Family Practice - MD
OFP Family Practice - DO
OFM Family Practice - DO -
Including Osteopathic
Manipulation
MPM General Preventive Medicine
MOH Hand-Orthopaedic Surgery
MPH Hand-Plastic Surgery
MSH Hand-Surgery
MMM Internal Medicine
MMV Internal Medicine-
Cardiovascular Disease PSY
MME Internal Medicine-Endocrinology
Diabetes and Metabolism
MMG Internal Medicine-
Gastroenterology
MMH
MMI
Disease
MMO Internal Medicine-Medical Oncology
MMN Internal Medicine-Nephrology
MMP Internal Medicine-Pulmonary Disease
MMR Internal Medicine-Rheumatology
MOQ Medicine - Otherwise Qualified
MPB Neurological Surgery-Including Back
MPN Neurology
MNS Neurological Surgery
MNM Nuclear Medicine
MOG Obstetrics and Gynecology
MPO Occupational Medicine
MOP Ophthalmology
MOS Orthopaedic Surgery
MOB Orthopaedic Surgery-
Including Back
MTO Otolaryngology
MAP Pain Management-Anesthesiology
MPP Pain Management-Pain Medicine
MHA Pathology
MEP Pediatrics
MPR Physical Medicine & Rehabilitation
MPS Plastic Surgery
MPD Psychiatry
MRY Radiology
MSY Surgery
MSG Surgery-General Vascular
MTS Thoracic Surgery
MPT Toxicology-Occupational Medicine
MET Toxicology-Emergency Medicine
MUU Urology
Attachment to Form 106
Rev. 4/14/00(A)
1...+...10....+...20....+...30....+...40....+...50....+...60
*******************************************************************************
******* This is piece 2. -- It begins at character 61 of table line 1. ********
*******************************************************************************
MD/DO Specialty Codes Non-MD/DO Specialty Codes
Dermatology
ACA Acupuncture
DCH Chiropractic
DCN Chiropractic-Neurology [FNa1]
DCO Chiropractic
-Orthopaedic [FNa1]
DCR Chiropractic - Radiology [FNa1]
DCS Chiropractic - Sports
Medicine [FNa1]
DCT Chiropractic -
Rehabilitiation [FNa1]
DEN Dentistry
OPT Optometry
POD Podiatry
Psychology
PSN Psychology-Clinical
Neuropsychology
Internal Medicine-Hematology
Internal Medicine-Infectious
MD/DO Specialty Codes
61..+...70....+...80....+...90....+....0....+...10....+...20..
s 107. The Qualified Medical Evaluator Panel Selection Form.
STATE OF CALIFORNIA GRAY DAVIS, GOVERNOR
----------------------------------------------------------------
DEPARTMENT OF INDUSTRIAL RELATIONS
INDUSTRIAL MEDICAL COUNCIL ADDRESS REPLY TO:
395 OYSTER POINT BLVD., STE. 102 P.O. Box 8888
SOUTH SAN FRANCISCO, CA 94080 San Francisco, CA 94128-8888
TEL: (650) 737-2700 (800) 794-6900 Fax: (650) 737-2911
INJURED WORKER INFORMATION
Panel # __________
Date of Request: ___________ Date of Issue: __________
Claim No.: _________________ Date of Injury: _________
Claims Administrator: ________________________________
To: ________________________________
________________________________
________________________________
----------------------------------------------------------------
SELECTED QUALIFIED MEDICAL EVALUATOR PANEL:
( ) PHYSICIAN'S NAME
ADDRESS Tel. No.:
SPECIALTY
YEARS IN PRACTICE
PHYSICIAN'S EDUCATION
PHYSICIAN'S TRAINING
( ) PHYSICIAN'S NAME
ADDRESS Tel. No.:
SPECIALTY
YEARS IN PRACTICE
PHYSICIAN'S EDUCATION
PHYSICIAN'S TRAINING
( ) PHYSICIAN'S NAME
ADDRESS Tel. No.:
SPECIALTY
YEARS IN PRACTICE
PHYSICIAN'S EDUCATION
PHYSICIAN'S TRAINING.
IMC FORM 107 Rev. 3/01/00
Note: Authority cited: Sections 139.2, 4061 and 4062, Labor Code. Reference: Section 139.2, Labor Code.
s 108. The Request for Qualified Medical Evaluator Panel Selection Instruction Form.
STATE OF CALIFORNIA GRAY DAVIS, GOVERNOR
----------------------------------------------------------------
DEPARTMENT OF INDUSTRIAL RELATIONS
INDUSTRIAL MEDICAL COUNCIL ADDRESS REPLY TO:
395 OYSTER POINT BLVD., STE. 102 P.O. Box 8888
SOUTH SAN FRANCISCO, CA 94080 San Francisco, CA 94128-8888
TEL: (650) 737-2700 (800) 794-6900 Fax: (650) 737-2911
To: Injured Worker This list of Qualified Medical Evaluator (QME) physicians is being issued to you because a "Request for a Qualified Medical Evaluator" form was received in our office. These physicians were randomly selected by a computer. The QME you choose will evaluate or make determinations on medical questions about your work injury. For injuries prior to 1/1/94, the QME performs the final permanent disability evaluation once your treating physician determines that you condition is permanent and stationary. For injuries as of 1/1/94, a QME is only used when there is a dispute over the primary treating physicians report.
Please take the following steps:
1) Select one QME physician off the list
Your claims administrator (or if none, employer) should not select the QME or influence you on which physician to pick. You may consult with an Information and Assistance Officer in your area by calling 1-800-736-7401 before making a selection. You may also consult with an attorney. If you decide to become represented by an attorney, you should not select a QME from the list. For injuries on or after 1/1/94, if your primary treating physician or an other physician(s) who has treated you for this injury is listed on your panel you must call the Industrial Medical Council (IMC) for a replacement since your primary treating physician(s) cannot also be your QME.
2) Call the QME physician's office to make your appointment.
Make it clear to the QME's office staff that you are calling for a "QME exam". The person at the doctor's office will ask you for information that you will find on the upper right corner of the attached form. If the doctor you choose from your panel cannot arrange an appointment for evaluation with you within 60 days of your call, the QME's office may not offer you a substitute QME who is not on the list.
You may:
a) select one of the other QMEs on the list;
b) call the IMC at 1-800-794-6900 to request that the unavailable QME on the list be replaced; or
c) agree to wait over the 60-day period to see any of the QMEs listed on your panel.
3) Review of medical records
You should be provided with copies of medical and non-medical records at least 20 days before information is to be provided to the QME. Within 10 days of receipt of the records, you may object to any non-medical records that might be sent to the QME for review.
If you plan to provide information to the QME, you must provide a copy of any medical or non-medical records you will be providing the QME to the claims administrator (or employer) at least 20 days before information is to be provided to the QME. Failure to send a copy of all records being sent to the QME may adversely affect your claim.
Your claims administrator (or employer) has 10 days after receiving the information to object to non-medical records. Copies of non-medical records objected to will not be provided to the QME but may be seen by the workers' compensation judge in your case, or by the QME at a later date if your claims administrator contests medical issues in your claim.
4) Your employer will pay for the exam
Your claims administrator (or employer) will pay for the exam, any translator services you need for the exam and for any reasonable cost to get you to and from the QME evaluation. You will also be paid disability benefits for each day of the evaluation, if you lose wages.
5) If the IMC does not provide you with a panel of QMEs within 15 working days of receipt of your request, you may choose any QME (with the proper specialty for your injury).
If the difference between "Date Request Received" and "Date of Issue" on your panel shows more than 15 working days, you may: choose to go to one of the QMEs on your panel; go to any Information and Assistance Office for assistance in choosing a QME; or call the Industrial Medical Council at 1-800-794-6900 to request a new panel of QMEs with the specialty you need for your evaluation.
6) A QME may not offer or solicit you to become your treating physician. However, you have the right to request the QME to become your treating physician. You may wish to consult with an Information and Assistance officer prior to this decision.
7) For additional information contact the IMC and request its pamphlets "Your Medical Evaluation" and "Fact Sheet for Injured Workers".
8) If the QME does not send the report on time, contact the IMC.
(a) 30 days of your appointment - if date of injury is on or after 1/1/94 or,
(b) 45 days of your appointment - if date of injury is between 1/1/91 and 12/31/93. IMC FORM 108 Rev. 3/01/00
IMC FORM 108 Rev. 3/01/00
Note: Authority cited: Sections 133, 139, 139.2, 4061 and 4062, Labor Code. Reference: Sections 139.2, 4061, 4061.5 and 4062, Labor Code.
s 109. The Notice of Qualified Medical Evaluator Unavailability Form.
STATE OF CALIFORNIA GRAY DAVIS, GOVERNOR
----------------------------------------------------------------
DEPARTMENT OF INDUSTRIAL RELATIONS
INDUSTRIAL MEDICAL COUNCIL ADDRESS REPLY TO:
395 OYSTER POINT BLVD., STE. 102 P.O. Box 8888
SOUTH SAN FRANCISCO, CA 94080 San Francisco, CA 94128-8888
TEL: (650) 737-2700 (800) 794-6900 Fax: (650) 737-2911
NOTICE OF QME UNAVAILABILITY
(Form must be filed 30 days prior to date of unavailability)
TO: EXECUTIVE MEDICAL DIRECTOR
INDUSTRIAL MEDICAL COUNCIL
Please check the appropriate boxes, if you will be unavailable for panel assignment for a period of 14 days or more.
( ) Please accept this notice that I will be unavailable for qualified medical evaluation panel selection assignment:
from ________________________ to _____________________
(month, day, year) (month, day, year)
( )Check here if you have filed for unavailabe during the calendar year.
( ) I will no longer be available for qualified medical evaluation assignment. Please remove my name from the list of Qualified Medical Evaluator.
----------------------------------------------------------------
( ) The above information is for all of my QME office locations.
( ) The above information is only for the QME office location(s)listed below.
QME Office Street Address: _____________________________________
City _____________________________CA, Zip Code__________________
QME Office Street Address: _____________________________________
City _____________________________CA, Zip Code _________________
QME Office Street Address: _____________________________________
City _____________________________CA, Zip Code _________________
Signature __________________Date ___________License # __________
Name(print/type) __________________________________
(Area Code) Phone # _____________________________
Note : It is not an acceptable reason for unavailability that a QME does not intend to perform evaluations for unrepresented workers. A QME who is unavailable may not perform QME evaluation until the QME has been reinstated. A QME who is unavailable for more than 90 days during the calendar year without good cause may be denied reappointment.
Send this completed form to: INDUSTRIAL MEDICAL COUNCIL
P.O. BOX 8888
SAN FRANCISCO, CA 94128-8888
(650) 737-2700 OR (800) 794-6900
(650) 737-2707 FAX
IMC Form 109 Rev. 3/01/00
Note: Authority cited: Sections 139 and 139.2, Labor Code. Reference: Sections 139.2, 4061 and 4062, Labor Code.
s 110. The Appointment Notification Form.
STATE OF CALIFORNIA GRAY DAVIS, GOVERNOR
----------------------------------------------------------------
DEPARTMENT OF INDUSTRIAL RELATIONS
INDUSTRIAL MEDICAL COUNCIL ADDRESS REPLY TO:
395 OYSTER POINT BLVD., STE. 102 P.O. Box 8888
SOUTH SAN FRANCISCO, CA 94080 San Francisco, CA 94128-8888
TEL: (650) 737-2700 (800) 794-6900 Fax: (650) 737-2911
QME APPOINTMENT NOTIFICATION FORM
To The Qualified Medical Evaluator: You are required by law to give notice on a prescribed form when an appointment has been made with you to perform a QME comprehensive medical evaluation. The Industrial Medical Council (IMC) has prescribed this form for this purpose. Please complete this form in its entirety, noting that you are legally required to include: the name and address of the employee, the name of the employer and claims administrator, and the appointment time and date. The IMC also requires that you serve this appointment notification form on the employee and the employer/insurer or if none, within five (5) days after having scheduled the injured worker to be seen for a QME comprehensive medical evaluation.
_______________________________________________________________
EMPLOYEE INFORMATION
_______________________________________________________________
NAME ___________________________________________________________
STREET ADDRESS _________________________________________________
(City, State, Zip) _____________________________________________
(AREA CODE) PHONE # __________________ SOCIAL SECURITY # _____________________
Social Security Number is for record-keeping purposes only.
DATE OF INJURY __________ PANEL # __________ CLAIM # __________
_______________________________________________________________
EMPLOYER INFORMATION
NAME ___________________________________________________________
STREET ADDRESS _________________________________________________
(City, State, Zip) _____________________________________________
(AREA CODE) PHONE # ____________________________________________
________________________________________________________________
INSURER or CLAIMS ADMINISTRATOR INFORMATION
________________________________________________________________
NAME ___________________________________________________________
COMPANY ________________________________________________________
ADDRESS ________________________________________________________
(AREA CODE) PHONE # ________________________
________________________________________________________________
DATE OF DATE OF TIME OF
APPOINTMENT CALL __________ APPOINTMENT __________ APPOINTMENT __________
LOCATION OF APPOINTMENT: _________________________
CERTIFIED INTERPRETER REQUIRED: (language) _____________________
COPY TO: ( )EMPLOYEE
( )CLAIMS ADMINISTRATOR (IF NONE, EMPLOYER)
Signature of QME __________________________ Date _______________
Name of QME (print/type) ______________________________
Address/Telephone ____________________________________
Note to Claims Administrator : The Administrative Director's regulation 10160 requires you to forward a completed DEU form 101, "Request for Summary Rating," together with all medical reports and medical records prior to the scheduled examination with the QME. You must also provide the employee with a DEU Form 100, "Employee's Disability Questionnaire," prior to the examination.
IMC FORM 110 Rev. 3/01/00
Note: Authority cited: Sections 139 and 139.2, Labor Code. Reference: Sections 139.2, 4061 and 4062, Labor Code.
s 111. The Qualified or Agreed Medical Evaluator Findings Summary Form.
Department of Industrial Relations, Industrial Medical Council, PO Box 8888, San Francisco, CA 94128w (650) 737-2700
Qualified or Agreed Medical Evaluator's Findings Summary Form
State of California
1. Employee Name (First, Middle, Last) 2. Social Sec No. (Optional) 3. Date of Injury (Mo/Dy/Yr)
Employee
4. Street Address City Zip 5. Telephone
Claims Administrator/ Employer
6. Name:
7. Street Address City Zip 8. Telephone
Exam Referral Schedule
9. Date of Appointment Call 10. Date of Initial Examination
11. Date of Referral for Medical Testing/Consultation
12. Date AME/QME's Report Served on all Parties
Disputed Medical Issues And Conclusion
13. The following medical issues will be used to determine the patient's eligibility for workers' compensation. Check the appropriate box and reference the corresponding page(s) or section of the med-legal reports for details.
Report
page(s)
or Pending
section or
Yes No Info. Not
Sent
a. Is there permanent disability? ______ ( ) ( ) ( )
b. Is the medical condition stable and not _____ ( ) ( ) ( )
likely to improve with active medical or
surgical treatment (i.e., is the condition
permanent and stationary)?
c. Did work cause or contribute to the injury ______ ( ) ( ) ( )
or illness?
d. If permanent disability exists, is _____ ( ) ( ) ( )
apportionment warranted?
e. Is there a need for current or future _____ ( ) ( ) ( )
medical care?
f. Can this employee now return to his/her usual job?
If yes: ( ) Yes ( ) No
i. Without restrictions ( )Yes ( )No if YES, Date:___________
ii. With restrictions ( )Yes ( ) No if YES, Date:___________
If restricted work is recommended., reference page(s)/section in report for details:
________________________________________________________________
Basis for Check box and refer to Report Pending
Conclusions page(s) or section page(s) or
inreport
or section Yes No Info. Not
Sent
14. Are there _____ ( ) ( ) ( )
subjective
complaints?
15. Are there any _____ ( ) ( ) ( )
abnormal physical or
psychological
examination
findings?
16. Are there any _____ ( ) ( ) ( )
relevant diagnostic
test results
(x-ray/laboratory)?
17. What are the diagnoses?
(List)____________________________________________________
___________________________________________________________
18. Were treating _____ ( ) ( ) ( )
physician's reports
reviewed?
19. Were other _____ ( ) ( )
physicians
consulted?
___________________________________________________________
QME 20. Signature _________________________Date: _______________
21. Name _________________________Specialty ____________________
22. Street Address ________________City __________Zip __________
_______________________________________________________________
23. Telephone __________________________Cal. # _________________
IMC FORM 111 Rev. 3/01/00 (OVER)
_______________________________________________________________
Department of Industrial Relations, Industrial Medical Council, PO Box 8888,
San Francisco, CA 94128 w (650) 737-2700
_______________________________________________________________
Instructions
To the QME or AME: You are required by Labor Code section 4061 to summarize the medical findings from your comprehensive medical-legal evaluation on the form prescribed by the Industrial Medical Council (IMC). Please complete the form in its entirety.
Employee Information : Fill in employee's full name, address, telephone number and date of injury.
Exam Referral Schedule : complete dates that patient called for an appointment, date of initial examination, date referred for consultation(s), if any, and date report served on all parties. Supplying these dates are a legal requirement.
Disputed Medical Issues and Conclusions : Complete this section by checking appropriate box and stating what page(s) or section of the medical legal report contain the narrative for details. If diagnostic or laboratory tests have been ordered and the results or a medical records request is pending, check that box. If you cannot render opinions because of pending information, please complete and serve the report to comply with the 30 day time requirement and state what issues could not be evaluated.
Basis for Conclusions: Check appropriate box and give page numbers or section where the narrative in the full report is found. For diagnoses, in addition to page numbers, please briefly summarize the diagnoses in lay terms where possible. Also, list name and specialty for other physicians who provided information used in the medical legal report.
Signature: Remember under the Labor Code, all your reports must be signed under the penalty of perjury. You are required to serve the medical legal report and this form on the employee, the claims administrator, (if none, employer) and the Disability Evaluation Unit (DEU) having jurisdiction over the employee's area of residence.
IMC Form 111 Rev. 3/01/00
Note: Authority cited: Sections 139, 139.2 and 4061, Labor Code. Reference: Sections 139.2 and 4061, Labor Code.
s 112. The Qualified or Agreed Medical Evaluator Extension Request Form.
STATE OF CALIFORNIA GRAY DAVIS, GOVERNOR
----------------------------------------------------------------
DEPARTMENT OF INDUSTRIAL RELATIONS
INDUSTRIAL MEDICAL COUNCIL ADDRESS REPLY TO:
395 OYSTER POINT BLVD., STE. 102 P.O. Box 8888
SOUTH SAN FRANCISCO, CA 94080 San Francisco, CA 94128-8888
TEL: (650) 737-2700 (800) 794-6900 Fax: (650) 737-2911
QME/AME TIME FRAME EXTENSION REQUEST- (For Late Reporting on Accepted Claims)
Please send this form to the Industrial Medical Council at the above address 5 days before your report is due to be served on the parties. Send a copy of this form to the employee and employer/insurer/claims administrator. The QME may not be entitled to payment for evaluations which are not submitted in a timely manner (Labor Code s 4062.5). If you need further information, please call us at (650) 737-2700 or 1-800-794-6900.
DATE OF EVALUATION: ___________________ DATE REPORT WILL BE SERVED: __________
THERE ARE ONLY THREE (3) VALID REASONS FOR AN EXTENSION, YOU ARE REQUIRED TO CHECK ONE OF THE THREE (3) BOXES LISTED BELOW. FORMS NOT FULLY COMPLETED WILL BE RETURNED.
REASON FOR REQUEST:
1. ( ) Lab/tests have not been completed - type of test(s) requested: ________________________________
2. ( ) Consulting specialist has not completed evaluation - type of specialist(s): __________ __________
For injuries between 1/1/91 and 12/31/93. If extension requested is beyond 90 days, from date of initial evaluation, please attach justification.
For injuries on or after 1/194. If extension requested is beyond 60 days, from date of initial evaluation, please attach justification
3. EXTENSIONS FOR GOOD CAUSE:
Extensions for Good Cause may not exceed an additional 15 days from the date the report is required to be served and must be approved by the Executive Medical Director. Please check the appropriate box and specify good cause.
A. ( ) Medical emergency of the evaluator or the evaluator's family.
B. ( ) Death in evaluator's family.
C. ( ) Natural disaster or other community catastrophes that interrupt the operation of the evaluator's office.
Specify Good Cause _____________________________________________
________________________________________________________________
Employee's Name ______________________ Date of Injury __________
Name of Employer ________________Claims Administrator __________
Name of QME (PRINT/TYPE) __________________QME NUMBER __________
Signature of QME ________________________________Date __________
Street Address __________City/Zip __________Telephone __________
________________________________________________________________
FOR IMC/DWC USE ONLY
( ) Extensions approved- form 113 ( ) Extension denied-Forms 114, 115
Executive Medical Director: ____________________Date __________
IMC FORM 112 Rev. 3/01/00
Note: Authority cited: Sections 139 and 139.2, Labor Code. Reference: Sections 139.2, 4060, 4061, 4062 and 4062.5, Labor Code.
s 113. The Time Extension Approval Form.
STATE OF CALIFORNIA GRAY DAVIS, GOVERNOR
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DEPARTMENT OF INDUSTRIAL RELATIONS
INDUSTRIAL MEDICAL COUNCIL ADDRESS REPLY TO:
395 OYSTER POINT BLVD., STE. 102 P.O. Box 8888
SOUTH SAN FRANCISCO, CA 94080 San Francisco, CA 94128-8888
TEL: (650) 737-2700 (800) 794-6900 Fax: (650) 737-2911
IMPORTANT: RETURN TO THE IMC WITHIN 15 DAYS.
Date: __________
TO:
EMPLOYEE'S NAME _____________________________
_____________________________
_____________________________
Claim Number: __________ Panel Number: __________
TIME EXTENSION APPROVAL
Your QME/AME doctor has asked for an extension of the time in which he/she is required to complete your medical evaluation. We are allowing the doctor extra time to do so. If you are unrepresented and the report is still not complete by ________________, you may either:
(1) accept the report when it is completed or
(2) ask for a replacement panel and repeat the QME process
You are required to make a decision, check, sign and return this form using the postage prepaid return envelope within 15 days.
( ) check here if you give up your right to a new QME panel at this time. You have up to the date the QME serves the report to call and request a new panel.
( ) check here if you wish to have a new QME panel sent if the report is not completed by the above date.
_________________________________ _____________________________
Signature Date
If you are represented, please consult your attorney.
If you have any questions please call (650) 737-2700/800-794-6900 or write to:
The Industrial Medical Council P.O. Box 8888 San Francisco, CA 94128-8888
IMC FORM 113 Rev. 3/01/00
Note: Authority cited: Sections 139 and 139.2, Labor Code. Reference: Sections 139.2, 4060, 4061, 4062 and 4062.5, Labor Code.
s 114. The Denial of Time Extension Form.
STATE OF CALIFORNIA GRAY DAVIS, GOVERNOR
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DEPARTMENT OF INDUSTRIAL RELATIONS
INDUSTRIAL MEDICAL COUNCIL ADDRESS REPLY TO:
395 OYSTER POINT BLVD., STE. 102 P.O. Box 8888
SOUTH SAN FRANCISCO, CA 94080 San Francisco, CA 94128-8888
TEL: (650) 737-2700 (800) 794-6900 Fax: (650) 737-2911
TO: DATE: _________________________________
Evaluator's Name ________________________________
________________________________
________________________________
Injured worker's Name ________________________________
________________________________
________________________________
Date of Injury: ________________________________
Case Number: ________________________________
Claim Number: ________________________________
Panel Number: ________________________________
DENIAL OF TIME EXTENSION
Your request for time extension for medical evaluation report submission has been denied for the following reason(s):
________________________________________________________________
________________________________________________________________
________________________________________________________________
The report is due within 45 days (for injuries occurring on or after 1/1/91 up to 12/31/93) or 30 days (for injuries occurring on or after 1/1/94) of the appointment. Please note Labor Code section 4062.5 states that the QME is not entitled to payment for evaluations which are not submitted in a timely manner and rejected by the applicant. The injured worker now has the option of accepting the late report or requesting a replacement.
IMC FORM 114 Rev. 3/01/00
Note: Authority cited: Sections 139 and 139.2, Labor Code. Reference: Sections 139.2, 4060, 4061, 4062 and 4062.5, Labor Code.
s 115. The Notice of Late Qualified Medical Evaluator Report Form.
STATE OF CALIFORNIA GRAY DAVIS, GOVERNOR
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DEPARTMENT OF INDUSTRIAL RELATIONS
INDUSTRIAL MEDICAL COUNCIL ADDRESS REPLY TO:
395 OYSTER POINT BLVD., STE. 102 P.O. Box 8888
SOUTH SAN FRANCISCO, CA 94080 San Francisco, CA 94128-8888
TEL: (650) 737-2700 (800) 794-6900 Fax: (650) 737-2911
IMPORTANT: RETURN TO THE IMC WITHIN 15 DAYS.
Date: __________________
TO:
EMPLOYEE'S NAME _________________________________
_________________________________
_________________________________
Claim Number: _______________ Panel Number: __________
NOTICE OF LATE QME REPORT - EXTENSION REQUEST DENIED
Your QME has not completed your medical evaluation report within the required time from the date of your evaluation. You can accept the delay of your evaluation or ask the IMC for a replacement panel and repeat the QME process.
You are required to make a decision, check, sign and return this form using the postage prepaid return envelope within 15 days. This time period may be extended upon a showing of good cause to the Medical Director.
Check here if you give up your right to a new QME panel at this time. If the QME does not serve the report by __________________, you may call and request a new panel.
Check here if you wish to have a new QME panel.
Signature: ____________________________ Date: ________________
If you are represented, please consult your attorney. If you have any questions please call (650) 737-2700/800-794-6900 or write to:
The Industrial Medical Council P.O. Box 8888 San Francisco, CA 94128-8888
cc: Claims Administrator QME
IMC Form 115 Rev. 3/01/00
Note: Authority cited: Sections 139 and 139.2, Labor Code. Reference: Sections 139.2, 4060, 4061, 4062 and 4062.5, Labor Code.
s 116. The Notice of Late Qualified Medical Evaluator Report Form -Extension Not Requested Form.
STATE OF CALIFORNIA GRAY DAVIS, GOVERNOR
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DEPARTMENT OF INDUSTRIAL RELATIONS
INDUSTRIAL MEDICAL COUNCIL ADDRESS REPLY TO:
395 OYSTER POINT BLVD., STE. 102 P.O. Box 8888
SOUTH SAN FRANCISCO, CA 94080 San Francisco, CA 94128-8888
TEL: (650) 737-2700 (800) 794-6900 Fax: (650) 737-2911
IMPORTANT: RETURN TO THE IMC WITHIN 15 DAYS
Date: __________
TO:
EMPLOYEE'S NAME: ________________________________
________________________________
________________________________
Claim Number: ______________________ Panel Number: __________
NOTICE OF LATE QME REPORT - NO EXTENSION REQUESTED
It has come to our attention that your QME doctor has not completed your medical evaluation report within the required time from the date of your evaluation. You can accept the delay of your evaluation report or ask the IMC for a replacement panel and repeat the QME process.
You are required to make a decision, check, sign and return this form using the postage prepaid return envelope within 15 days. This time period may be extended upon a showing of good cause to the Medical Director.
( ) Check here if you give up your right to a new QME panel at this time. You have up to the date the QME serves the report to call and request a new panel.
( ) Check here if you wish to have a new QME panel.
Signature: _____________________________ Date: _________________
If you are represented, please consult your attorney.
If you have any questions, please call (650) 737-2767/800-794-6900 or write to:
Industrial Medical Council P.O. Box 8888 San Francisco, CA 94128-8888
cc: Claims Administrator QME
IMC Form 116 Rev. 3/01/00
Note: Authority cited: Sections 139 and 139.2, Labor Code. Reference: Sections 139.2, 4060, 4061, 4062 and 4062.5, Labor Code.
s 117. Qualified Medical Evaluator Continuing Education Response Form.
DEPARTMENT OF INDUSTRIAL RELATIONS
INDUSTRIAL MEDICAL COUNCIL ADDRESS REPLY TO:
395 Oyster Point Blvd., Ste. 102 P.O. Box 8888
South San Francisco, CA 94080 San Francisco, CA
94128-8888
Tel: (650) 737-2700 (800) 794-6900 Fax: (650) 737-2711
STATE OF CALIFORNIA GRAY DAVIS, GOVERNOR
industrial medical council course evaluation
As a part of the IMC's ongoing efforts to ensure that courses for Qualified Medical Evaluators offer valuable information on California's Workers' Compensation-related medical evaluation issues, we are asking attendees of the IMC approved courses (including distance learning programs) to complete the following Course Evaluation.
Date of Course: __________ Course Provider: __________ __________ Course Name: __________ __________ Maximum Course Hours Available __________ __________ Hours Completed __________ __________
Excellent Good Satisfactory Fair Poor
Content Hand-out material 5 4 3 2 1
Adequate/Accurate new information 5 4 3 2 1
Educational Objective Met 5 4 3 2 1
Pertinence to QME evaluations 5 4 3 2 1
Knowledge of presenters 5 4 3 2 1
Syllabus Legibility 5 4 3 2 1
Adequacy of Room 5 4 3 2 1
Adequacy of Audio Visual 5 4 3 2 1
Overall Rating 5 4 3 2 1
What improvement(s) would you suggest? __________ __________ __________ __________ __________ __________ __________
TO ALL ATTENDEES: PLEASE RETURN THIS FORM TO THE IMC
All providers shall be required to provide this response form (postage paid) to all attendees and shall advise all attendees that the form should be promptly returned to the IMC at the address on the back of this form.
IMC Form 117 Rev. 3/01/00(A)
Note: Authority cited: Section 139.2, Labor Code. Reference: Section 139.2, Labor Code.
s 118. Application for Accreditation or Re-Accreditation As Education Provider.
Department of Industrial Relations
Industrial Medical Council
P. O. Box 8888
San Francisco, CA 94128-8888
______________________________________________________________
APPLICATION FOR ACCREDITATION OR RE-ACCREDITATION AS
EDUCATION PROVIDER
FOR OFFICE USE ONLY _______APPROVED __________DENIED
NO.__________ DATE____________ INITIALS ____________
SECTION 1 - PROVIDER
______________________________________________________________
NAME OR PROVIDER: ____________________________________________
ADDRESS ______________________________________________________
CITY _______________________ STATE _____________ ZIP__________
DIRECTOR OF EDUCATION ________________________________________
PHONE (___)_______ FAX(___)________ E-MAIL ADDRESS ___________
TYPE OF ORGANIZATION _________________________________________
LENGHT OF TIME IN BUSINESS __________
NATURE OF BUSINESS/MISSION STATEMENT
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
PAST CONTINUING EDUCATION PROGRAMS
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
ACCREDITING AGENCIES WHO HAVE APPROVED PAST PROGRAMS
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
IMC FORM 118 (Rev. 7.01)
SECTION 2 - EDUCATION PROGRAM
PROGRAM TITLE ________________________________________________
TYPE OF PROGRAM
DISABILITY EVALUATION REPORT WRITING COURSE ( )
QME CONTINUING EDUCATION PROGRAM ( )
DISTANCE LEARNING PROGRAM
DISTANCE LEARNING HOURS ( )
TOTAL COURSE HOURS ( )
PROGRAM OBJECTIVES
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
LOCATION(S) OF PROGRAMS(S) _____________________DATES
______________________________________________________________
______________________________________________________________
______________________________________________________________
(1) INSTRUCTOR _________________________ HOURS _______________
TOPIC __________________________________
CONTENT
______________________________________________________________
______________________________________________________________
______________________________________________________________
(2) INSTRUCTOR _________________________ HOURS _______________
TOPIC __________________________________
CONTENT
______________________________________________________________
______________________________________________________________
______________________________________________________________
(3) INSTRUCTOR _________________________ HOURS _______________
TOPIC __________________________________
CONTENT
______________________________________________________________ (continued)