When a California injured employee has no attorney and no application for adjudication, the claims administrator uses this form to ask the Disability Evaluation Unit to rate the panel QME's report. It goes to the QME with all medical reports and records before the exam, and the QME sends it back to the DEU as the cover sheet for the finished evaluation.
The claims administrator completes the claim, employer, employee, occupation and earnings details and serves the form on the employee. The QME adds the physician name and exam date.
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Request for Summary Rating Determination of Qualified Medical Evaluator's Report
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Mostly the claims administrator, who completes the claim, employer, employee, occupation and earnings sections, sends it with all medical records to the evaluating physician, and serves it on the employee. The QME's part is small: the physician name and exam date, then using the form as the DEU cover sheet.
The QME submits the completed medical evaluation, together with the employee's DEU Form 100 when the employee is unrepresented, to the Disability Evaluation Unit district office named on the form, using DWC-AD 101 as the cover sheet. Copies of the report and Form 100 go to the claims administrator and the employee.
Only when the injured employee is unrepresented and has not filed an application for adjudication; the form's instructions limit it to those cases. It must reach the evaluating physician, with the medical records, before the scheduled examination.