Form 105 Request for Qualified Medical Evaluator Panel - California

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.

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Form Details:

  • Released on September 1, 2015;
  • 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 105 by clicking the link below or browse more documents and templates provided by the California Department of Industrial Relations.

Download Form 105 Request for Qualified Medical Evaluator Panel - California

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