Form 110 "Qme Appointment Notification Form" - California

What Is Form 110?

This is a legal form that was released by the California Department of Industrial Relations - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on October 1, 2013;
  • The latest edition provided by the California Department of Industrial Relations;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form 110 by clicking the link below or browse more documents and templates provided by the California Department of Industrial Relations.

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Download Form 110 "Qme Appointment Notification Form" - California

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State of California
Print Form
Division of Workers' Compensation-Medical Unit
Reset Form
QME Appointment Notification Form
Please complete this form in its entirety.
The Administrative Director requires that you serve this appointment notification form on
the employee and the claims administrator, or, if none the employer, and their attorneys in a represented case, if known, within five (5)
business days after having scheduled the injured worker to be seen for a QME comprehensive medical-legal evaluation. You may not
cancel the appointment less than six (6) calendar days prior to the appointment date, except for good cause (See, 8 Cal. Code Regs. §34). If
you reschedule an appointment, review regulation 34 and the ethical rules in regulation 41 (See, 8 Cal Code Regs. §§ 34, 41(a) (7) and (a)
Employee Information (
Completion of this section is required)
Employee Name
Phone Number
Employee Street Address
Employee City
State
Zip Code
Date of Injury
Panel Number
Claim or Case Number
Employer Information
Employer Name
Employer Street Address
Employer City
State
Zip Code
Claims Administrator Information (
Completion of this section is required)
Claims Administrator Name (Insert the name of the person handling the claim)
Phone Number
Claims Administrator Company (Insert the name of the company handling the claim)
Claims Administrator Street Address
Claims Administrator City
State
Zip Code
Appointment Information
(Completion of this section is required)
Date of appointment call:
Date of Appointment:
Time of appointment:
Zip Code
Examination address
Examination City:
Records should be sent to the following address:
Zip Code
Street address or P.O. Box
City:
Is a certified interpreter required? Yes
No
If an interpreter is required, indicate language:
QME Name:
State
QME City
Zip Code
QME Street Address
Date Signed:
Signature of the QME:
Note to Claims Administrator: The Administrative Director's regulation 10160 requires you to forward a completed, DWC-AD form
101(DEU) (Request for Summary Rating Determination of Qualified Medical Evaluator's Report) (see, 8 Cal. Code Regs. §§ 10160
and 10161) together with all medical reports and medical records prior to the scheduled examination with the QME. You must also
provide the employee with a DWC-AD form 100 (DEU) (Employee's Disability Questionnaire)(See, 8 Cal. Code Regs. §§ 10160 and
10161) prior to the examination.
Page 1 of 2
QME Form 110 (rev. 10/2013)
State of California
Print Form
Division of Workers' Compensation-Medical Unit
Reset Form
QME Appointment Notification Form
Please complete this form in its entirety.
The Administrative Director requires that you serve this appointment notification form on
the employee and the claims administrator, or, if none the employer, and their attorneys in a represented case, if known, within five (5)
business days after having scheduled the injured worker to be seen for a QME comprehensive medical-legal evaluation. You may not
cancel the appointment less than six (6) calendar days prior to the appointment date, except for good cause (See, 8 Cal. Code Regs. §34). If
you reschedule an appointment, review regulation 34 and the ethical rules in regulation 41 (See, 8 Cal Code Regs. §§ 34, 41(a) (7) and (a)
Employee Information (
Completion of this section is required)
Employee Name
Phone Number
Employee Street Address
Employee City
State
Zip Code
Date of Injury
Panel Number
Claim or Case Number
Employer Information
Employer Name
Employer Street Address
Employer City
State
Zip Code
Claims Administrator Information (
Completion of this section is required)
Claims Administrator Name (Insert the name of the person handling the claim)
Phone Number
Claims Administrator Company (Insert the name of the company handling the claim)
Claims Administrator Street Address
Claims Administrator City
State
Zip Code
Appointment Information
(Completion of this section is required)
Date of appointment call:
Date of Appointment:
Time of appointment:
Zip Code
Examination address
Examination City:
Records should be sent to the following address:
Zip Code
Street address or P.O. Box
City:
Is a certified interpreter required? Yes
No
If an interpreter is required, indicate language:
QME Name:
State
QME City
Zip Code
QME Street Address
Date Signed:
Signature of the QME:
Note to Claims Administrator: The Administrative Director's regulation 10160 requires you to forward a completed, DWC-AD form
101(DEU) (Request for Summary Rating Determination of Qualified Medical Evaluator's Report) (see, 8 Cal. Code Regs. §§ 10160
and 10161) together with all medical reports and medical records prior to the scheduled examination with the QME. You must also
provide the employee with a DWC-AD form 100 (DEU) (Employee's Disability Questionnaire)(See, 8 Cal. Code Regs. §§ 10160 and
10161) prior to the examination.
Page 1 of 2
QME Form 110 (rev. 10/2013)
Declaration of Service
I declare that I am a resident of or employed in the county where the mailing took place. I am over the age of
eighteen years and I am not a party to this case, my business or residence address is:
On
, I served this QME Appointment Notification Form, the original, or a true and correct copy
of the original, which is attached, on each of the persons or firms named below, by placing it in a sealed envelope,
addressed to the person or firm named below, and by:
A
depositing the sealed envelope with the U. S. Postal Service with the postage fully prepaid.
placing the sealed envelope for collection and mailing following our ordinary business practices. I am
readily familiar with this business’s practice for collecting and processing correspondence for mailing. On
B
the same day that correspondence is placed for collection and mailing, it is deposited in the ordinary
course of business with the U. S. Postal Service in a sealed envelope with postage fully prepaid.
placing the sealed envelope for collection and overnight delivery at an office or a regularly utilized drop
C
box of the overnight delivery carrier.
placing the sealed envelope for pick up by a professional messenger service for service. (Messenger must
D
return to you a completed declaration of personal service.)
E
personally delivering the sealed envelope to the person or firm named below at the address shown below.
Person or firm served
Street Address
Method of
Service
City
State
Zip Code
Person or firm served
Street Address
Method of
Service
City
State
Zip Code
Person or firm served
Street Address
Method of
Service
City
State
Zip Code
Person or firm served
Street Address
Method of
Service
City
State
Zip Code:
I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
Date:
at
, California.
Type or print name
Signature _____________________________________________
QME Form 110 (rev. 10/2013)
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