After scheduling an injured worker for a comprehensive medical-legal evaluation, a California panel QME notifies the parties on this form. It lists the employee, employer and claims administrator, the panel number, appointment date, time and exam address, where records should be sent and whether a certified interpreter is needed, followed by a declaration of service on page 2.
The QME or the QME's office completes the form and the QME signs it. Whoever serves it, who must be over 18 and not a party to the case, signs the declaration of service.
Download the current version from the source each time; forms change without notice.
QME Appointment Notification Form
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
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Within five business days after the QME schedules the injured worker for the comprehensive medical-legal evaluation. It goes to the employee and the claims administrator, or the employer if there is no claims administrator, and to their attorneys in a represented case, if known.
Not less than six calendar days before the appointment, except for good cause, under 8 CCR 34. A QME who reschedules should review regulation 34 and the ethics provisions in 8 CCR 41(a)(7) and (a)(8), as the form itself instructs.
The declarant states they live or work in the county where mailing took place, are over 18 and are not a party, then lists each person or firm served with address and a service method from A to E: postal mail, business mail collection, overnight delivery, messenger or personal delivery.