Bulletin No. 35-04
July 15, 2004

QME request forms must be mailed to the DWC medical unit

Beginning immediately, the DWC Medical Unit will only accept a Request for Qualified Medical Evaluator form (IMC Form 106) if it is received in the U.S. Mail. Forms received by FAX, e-mail or any other form of electronic submission will not be accepted. Requestors must use the existing form 106 until a new one is promulgated. An exact duplication of the IMC Form 106 will also be accepted if it is reproduced on the claims administrator's letterhead. No other changes are acceptable.

Panel requests should be mailed to: DWC Medical Unit, P. O. Box 8888, San Francisco, CA 94128. It is important that the correct mailing address be used and not another, because the 15-day time frame for issuing a panel starts from the date the DWC Medical Unit receives the request.