Form 105 Request for Qualified Medical Evaluator Panel - California

What Is Form 105?

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.

FAQ

Q: What is Form 105?
A: Form 105 is a Request for Qualified Medical Evaluator (QME) Panel.

Q: What is a Qualified Medical Evaluator Panel?
A: A Qualified Medical Evaluator Panel is a list of three QMEs provided by the Division of Workers' Compensation.

Q: When should Form 105 be used?
A: Form 105 should be used when a workers' compensation claim requires a QME evaluation.

Q: Who can request a QME Panel using Form 105?
A: Employers, insurance carriers, and injured workers can request a QME Panel using Form 105.

Q: How do I submit Form 105?
A: Form 105 should be completed and submitted electronically or by mail to the Division of Workers' Compensation.

Q: What happens after submitting Form 105?
A: The Division of Workers' Compensation will review the request and provide a QME Panel to the requesting party.

Q: How can I select a specific QME from the panel?
A: The requesting party can select a specific QME from the panel, or the QME can be randomly selected by the parties involved.

Q: What is the purpose of a QME evaluation?
A: A QME evaluation is conducted to determine the extent of an injured worker's medical condition and any resulting disability.

Q: Can the QME evaluation be used as evidence in a workers' compensation case?
A: Yes, the QME evaluation can be used as evidence in a workers' compensation case.