Newsline No. 27-09 printer image Printer friendly

May 14, 2009


New workers' compensation Medical Unit forms required effective May 19, 2009

The Division of Workers’ Compensation (DWC) Medical Unit reminds all concerned that the qualified medical evaluator (QME) panel requests submitted on QME form 105 or 106, postmarked on or after May 19, 2009, must be on the most recently adopted forms. The new forms read “rev. February 2009” at the bottom left corner of the form.

Expired forms will no longer be processed or returned to the sender. A letter notifying the requestor of the problem will be sent instead.                  

Anyone interested in creating their own version of the form, may do so if they provide the information exactly as the newly approved form. The same font, spacing and format are required.

The current forms are available on the Web at You may also contact the DWC Medical Unit directly at 510-286-3700 for additional information