Qualified medical evaluator regulations
Workers' compensation proposed regulations
Qualified medical evaluator
Title 8, California Code of Regulations
Sections 1 - 159
Filed with secretary of state Jan. 13, 2009
Effective Feb. 17, 2009
- Final statement of reasons and updated informative digest
version 
version - Updated informative digest version version
- Final text of regulations version version
Forms
- 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
*To open attachment, open form then click on paperclip icon on left side margin, then double click on attachment - QME Form 106 Request For QME panel under Labor Code Section 4062.2 – represented and attachment to form 106
*To open attachment, open form then click on paperclip icon on left side margin, then double click on attachment - 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 medical evaluator's findings summary form (unrepresented cases only)
- 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 - form has been removed and will be replaced with an updated version at a later date
- QME Form 118 Application for accreditation or re-accreditation as education provider - Form instructions
- 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 - Form instructions
- QME Form 124 QME disclosure of specified financial interests
Comment Chart
History of qualified medical evaluator
2nd 15 day comment period - Nov. 6, 2008
- Amended notice of modification to text of regulations version version
- Amended text of proposed regulations version version
- Notice of modification to text of regulations version version
- Text of proposed regulations version version
- QME Form 105 Request For QME panel under Labor Code Section 4062.1 – unrepresented and attachment to form 105
*To open attachment, open form then click on paperclip icon on left side margin, then double click on attachment - QME Form 106 Request For QME panel under Labor Code Section 4062.2 – represented and attachment to form 106
*To open attachment, open form then click on paperclip icon on left side margin, then double click on attachment - 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 medical evaluator's findings summary form only unrepresented injured worker
- 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
Forms proposed for the first 15 day period that have been completely revised
- 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
1st 15 day comment period - Jul. 10, 2008
- Notice of modification to text of regulations version version
- Text of proposed regulations version version
- 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 medical evaluator's findings summary form only unrepresented injured worker
- 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 - form has been removed and will be replaced with an updated version at a later date
- 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
Forms proposed in the 45 day period that have been completely revised
- 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
- Transcript of public hearing testimony Los Angeles version
- Transcript of public hearing testimony Oakland version
45 day comment period - Jan 17, 2008
- Notice of proposed rulemaking version version
- Initial statement of reasons version version
- Text of proposed regulations version version
- 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 medical evaluator's findings summary form only unrepresented injured worker
- 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 - form has been removed and will be replaced with an updated version at a later date
- 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 123 QME or AME conflict of interest disclosure form and objection or waiver
- QME Form 124 QME disclosure of specified financial interests
- QME Form 100 Application for appointment as qualified medical evaluator
- QME Form 101 Statement of citizenship, alienage, and immigration status for public benefits
- QME Form 102 Registration for QME competency examination
- IMC Form 103 QME fee assessment form
- IMC Form 104 Reappointment application as qualified medical evaluator and attachment
- IMC Form 106 Request for qualified medical evaluator and attachment
- IMC Form 107 QME panel selection
- IMC Form 108 QME panel selection instruction form (injured worker information)
- IMC Form 109 QME notice of unavailability
- IMC Form 110 QME appointment notification form
- IMC Form 111 Qualified or agreed medical evaluator findings summary form
- IMC Form 112 QME/AME time frame extension request
- IMC Form 113 Time extension approval
- IMC Form 114 Time extension denial
- IMC Form 115 Notice of late QME report – extension request denied
- IMC Form 116 Notice of late QME report – no extension requested
- IMC Form 118 Application for accreditation or re-accreditation as education provider
- IMC Form 119 Faculty disclosure of commercial interest
- IMC Form 81556 Treating physician’s determination of medical issues
Time and place of public hearing
A public hearing has been scheduled to permit all interested persons the opportunity to present statements, arguments, either orally or in writing, with respect to the subject noted above. The hearing will be held at the following time and place:
| Date: | Jan. 14, 2008 |
| Time: | 10:00 a.m. to 5:00 p.m. or conclusion of testimony |
| Place: | Ronald Reagan State Office Building - auditorium 300 South Spring Street Los Angeles, California 90013 |
| Date: | Jan. 17, 2008 |
| Time: | 10:00 a.m. to 5:00 p.m. or conclusion of testimony |
| Place: | Elihu Harris State Building - auditorium 1515 Clay Street Oakland, CA 94612 |
Camera usage will be allowed in only one area of the hearing room. To provide everyone a chance to speak, public testimony will be limited to 10 minutes per speaker and should be specific to the proposed regulations. Testimony exceeding 10 minutes may be submitted in writing.
Written comments should be addressed to:
Maureen Gray, regulations coordinator
Department of Industrial Relations
Division of Workers' Compensation
1515 Clay Street, 18th floor
Oakland, CA 94162
The division's contact person must receive all written comments concerning the proposed modifications to the regulations no later than 5:00 p.m. on Jan. 17, 2008. Written comments may be submitted by facsimile transmission (FAX), addressed to the contact person at (510) 286-0687. Written comments may also be sent electronically (via e-mail), using the following e-mail address: dwcrules@hq.dir.ca.gov.