When a California QME or AME cannot serve a medical-legal report on time, this form asks the DWC Medical Unit for more time. A 30-day extension covers lab or test results or a consulting physician's report not yet received. A 15-day extension covers a medical emergency or death in the evaluator's family, or a natural disaster that interrupted the office.
The QME or AME completes and signs it with the exam date, the date the report will be served and the reason. The person who serves copies signs the declaration of service on page 2.
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QME/AME Report Time Frame Extension Request
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Thirty days when lab or test results, or a consulting physician's report, have not been received. Fifteen days for a medical emergency of the evaluator or a family member, a death in the evaluator's family, or a natural disaster or community catastrophe that interrupted the office.
At least 5 days before the report is due to be served on the parties. It goes to the DWC Medical Unit with the completed proof of service, and copies go to the employee and the claims administrator. Filing late risks the report being untimely and unpaid under Labor Code 4062.5.
The form points evaluators to 8 CCR 38(i) for extensions of time on supplemental reports. Form 112 itself is framed around the comprehensive medical-legal report, with reasons tied to pending tests, consultations, emergencies and disasters.