QME Forms 105 and 106: Requesting a QME Panel in California

Which QME form do I need: 105 or 106?

Use Form 105 if you do not have a workers' comp attorney. Use Form 106, filed online, if you do.

A Qualified Medical Evaluator, or QME, is an independent doctor who resolves medical disputes in a California workers' comp claim. This page covers the paperwork: which form starts the process, how to fill it out, and where it goes. For what a QME actually does at the exam, see how the QME process works. These forms request a QME, not an Agreed Medical Evaluator; if your side is weighing an AME instead, see QME vs AME.

California splits the request by whether a worker has a lawyer. QME Form 105 is the Request for Qualified Medical Evaluator Panel for an unrepresented employee. Either the worker or the claims administrator can submit it. (The claims administrator is the insurance company or employer handling the claim.) Labor Code section 4062.1 is the law behind that form. QME Form 106 is the panel request used once an attorney represents the worker, and Labor Code section 4062.2 is the law behind it. Since October 1, 2015, represented requests are filed electronically through the state's online system, not mailed on paper.

A third form, QME Form 110, is not something you fill out yourself. The evaluator's office completes it once your exam date is set, and it tells everyone when and where the appointment happens.

How do I fill out and file QME Form 105?

Fill in the injury and party details, check why you want a panel, sign it, and mail it to the DWC Medical Unit with a Proof of Service.

Form 105 asks for your date of injury, claim number, and the medical specialty you want on the panel; you pick only one specialty. For tips on picking a specialty and deciding which name to keep on the panel later, see how to choose a QME doctor. You also check one reason for the request: a denied claim or compensability dispute, an objection to what your primary treating physician, or PTP, decided about your disability or future care, a dispute over newly claimed body parts, or another listed reason.

1. Fill in the employee section and the employer or claims administrator section completely, printed or typed.
2. If the dispute is about whether the injury is work related, attach the claims administrator's denial notice or its request for an evaluation.
3. Sign and date the form, then complete the attached Proof of Service.
4. Mail the signed form and Proof of Service to the Division of Workers' Compensation, Medical Unit, P.O. Box 71010, Oakland, CA 94612. The Medical Unit can be reached at (510) 286-3700 or (800) 794-6900.
5. Mail or deliver a signed copy to your claims administrator. If you are the claims administrator, serve a copy on the worker instead.

A form that is missing information gets sent back with an explanation of what is incomplete, which can slow your panel down. Check every field before you mail it.

How do I request a panel with QME Form 106 if I have a lawyer?

You do not mail a paper Form 106 anymore. Your side submits the request through the DWC's online system, and a panel usually issues right away.

This path covers claims with an injury date on or after January 1, 2005. The requesting side logs into the DWC's online QME system and enters the case and party details. It attaches the denial notice or written objection that started the dispute, then submits the request. The system assigns a panel of three evaluators right away in most cases, using the specialty standards in Labor Code section 139.2.

Generating the panel online is not the last step. The requesting party still has to print the request, the panel list, and any attached documents. A paper copy of all three then goes to the other side, with a Proof of Service, within one working day of generating the list. Mailing a paper QME Form 106 has not worked since September 3, 2015. The one exception is a small group of cases with an injury date before January 1, 2005, where both sides agree to use the paper form.

When can I request a QME panel?

You can ask once a real medical dispute exists, such as a denied claim or an objection to your treating doctor's opinion on disability or care.

For an unrepresented worker, a Form 105 request follows a specific trigger. The claims administrator denied the claim or asked for an evaluation to decide if the injury is work related, or a party objects to the primary treating physician's opinion on temporary disability, permanent disability, or future medical care.

For a represented worker, the clock starts differently. Either side may ask for a panel no earlier than the first working day that falls at least 10 days after the claims administrator mailed its denial notice, or after either side mailed a written objection to the treating doctor's report.

How many days do I have to strike a QME?

In a represented case, each side gets 10 days from when the panel is served to strike one name. Unrepresented workers do not strike; they pick one evaluator instead.

These two paths work differently, and mixing them up costs people time.

In a represented claim, after the online system serves the three-name panel, each side has 10 days to strike one evaluator from it. That leaves one evaluator standing, and that doctor becomes the QME. If a side lets that period pass without striking, the other side may pick any evaluator still on the list. Our guide to striking a QME panel covers how to use that strike wisely.

An unrepresented worker does not strike anyone. Instead, Labor Code section 4062.1 gives the worker 10 days from the panel's issuance to pick one of the three evaluators, schedule the exam, and tell the employer. Let that time run out, and the employer may choose the evaluator and arrange the appointment instead.

What is the QME appointment notification form, and where does it go?

Form 110 is completed by the evaluator's office, not you. It must go out within 5 business days of booking your exam and lists the date, time, and address.

Once an exam date is set, the evaluator's staff fills out QME Form 110 and mails or faxes it to the worker and the claims administrator, or the employer if there is no claims administrator, within 5 business days of making the appointment. In a represented case, a copy also goes to each side's attorney if one is known. The form states the exam date, time, and address, where medical records should be sent, and whether a certified interpreter is needed.

Title 8 regulation section 34 also limits canceling that appointment. The evaluator generally cannot cancel less than 6 business days before the exam without good cause, and has to put the reason in writing. A canceled exam has to be rescheduled within 60 calendar days unless both sides agree in writing to wait longer. Once the exam itself happens, see what happens after a QME exam for the report deadline and your next steps.

Holding the right form is only the first step. A missed deadline, the wrong specialty box, or a late strike can change which doctor evaluates your claim and how your case moves from there.

If you are unsure whether you count as represented for QME purposes, whether to use Form 105 or Form 106, or what to do with a Form 110 you just received, a short call can save you a mistake that is hard to undo later. Eman Yazdchi's office offers a free consultation and reviews each matter individually before deciding whether to take it on.

Call (661) 273-1780 or use the contact form to ask about your QME paperwork. For the other forms you may need during a claim, see our workers' comp forms guide.