IMC FORM 110
QME Appointment Notification Form
This form may be used to fulfill the requirement of notifying the
employer/insurer and the employee of a scheduled appointment.
IMC FORM 111
Qualified or Agreed Medical Evaluator's
Findings Summary
This cover form summarizes a QME's findings and should be attached to panel
QME and AME reports.
FORM DEU 100
Employee's Permanent Disability
Questionnaire
The injured worker completes this prior to QME or seeing you in your office.
This form must accompany the QME report.
FORM DEU 101
Request for Summary Rating Determination
(of AME's or QME's Report)
The adjuster completes this form which must accompany QME report.
IMC FORM 112
QME & AME Time Frame Extension Request
This form may be used when there is a valid reason to request that more time
be allotted to complete the medical-legal report. Form must be submitted 5
days prior to the report due date.
IMC FORM 109
Notice of QME Unavailability
This form should be used by a QME who wants to inform the IMC that he/she will
not be available to perform evaluations for over 14 days due to circumstances
such as a prolonged vacation. The form should be submitted at least 30 days
prior to the date of unavailability.
IMC FORM 100
Application for Appointment as Qualified
Medical Examiner
IMC FORM 102
QME Exam Packet
A physicians who is applying to become QME will
need this information.
IMC FORM 104
Reappointment Application as QME
This is used by QME's who want to be reappointed to another term as a QME.
IMC FORM 103
Annual QME Fee Calculation
This form may be used by QME's who need to pay the annual fee.
