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Notes: A Stepwise Guidebook on Filling out QME Form 121 State Of California Dir Ca Online

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The Definite Guide to QME Form 121 State Of California Dir Ca

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Find out How to Write Down the QME Form 121 State Of California Dir Ca

welcome to the training video for the.online forum 1:06 panel request system.my name is Katherine and I will be.walking you through the process of.submitting a represented initial panel.request you can access the online panel.request system by going to the DW see.medical unit web page once you've.accessed the online panel request system.from the medical unit homepage you'll be.taken to the beginning of the forum.before we start let's look at some.general features if you look to the.right this says step one of eight this.lets the user know what step of the.forum they are in similarly the top row.has page buttons this also lets the user.know what section of the forum they are.in you cannot proceed to the next stage.until you finish the current page any.field that has an asterisk next to it.means that it is mandatory for the user.to complete anything that has a question.mark next to it is what we call a.tooltip it gives the user instruction or.information about the field that it is.next to let's begin filling out the form.for the date of injury you can either.manually type in the date or use the.calendar widget that's provided for you.for requesting party the available.choices are applicant attorney defense.attorney or Claims Administrator for.name of treating physician there's.another tool tip it lets you know that.if you do not know the name of the.treating physician you may enter unknown.for the first name and unknown for the.last name for specialty of treating.physician there's a drop-down list it.lists the specialties in alphabetical.order other is at the very bottom you.can use the drop-down list or you can.type a letter of the alphabet and it.will take you to that section of the.list the same logic goes for qme.specialty requested.and for opposing parties qme specialty.preferred the only difference is that at.the very bottom it says unknown when you.get to the Labor Code section depending.what dispute your request is for the.following information may change if you.choose a 4060 dispute your dispute type.is compensability it asks for the date.of report being objected to and the date.of request for comprehensive exam if you.have a forty sixty-one dispute your.available choices are permanent.disability and future medical treatment.and here it asks you for the date of.objection communication if you choose.forty sixty two your dispute type.choices are temporary disability.permanent and stationary status work.restriction ability to return to work.apportionment diagnosis and causation it.also asks you for the date of.obstruction communication but note.there's another question it says was.written objection communicated within 20.days of your receipt of the report for.which objections are being made if yes.that satisfies the question but if no.it'll ask you another question.it'll tell you to tell them the reason.why it was made more than 20 days from.objected report receipt date if you.choose mutual agreement that satisfies.the question but if you choose good.cause you are required to give an.explanation note there's another tool.tip this lets you know that the.character limit for this box is 2,000.characters we're gonna go ahead and.choose a 4060 dispute.data report being objected to will be.September 1st 2008 and data requests for.comprehensive exam will be October 1st.2008 now remember this form is for only.dates of injuries 1 105 and after 4.represented cases on the initial panel.request if you have a date of injury.before that and you attempt to use this.form this is what will happen you will.receive an error saying that you cannot.use this system because the date of.injury is part 2 1 105 you can contact.the medical unit for any further.questions so let's change our date of.injury back to its original and proceed.now we're at the employee information.page let's start completing this.note when you get to city and state.these fields are disabled all you have.to do is enter a zip code.and the system will automatically.populate the city and state for you if.you have cities that share a zip code.you can use the drop-down menu and.choose the appropriate city let's say.for example your injured worker lives.outside of California we'll enter an.out-of-state zip code.a question arrives it asks you is there.a geographical agreement for the panel.request and a tooltip is also there.which lets you know that in order for.you to have a panel in the state of.California you need to provide a zip.code for the employee the alternate.address or the applicant attorney if you.answer yes that there is an agreement.you have the opportunity to enter an.alternate address if you answer no when.you're issued a panel it will default to.the applicant attorneys zip code let's.change this zip code back to a ZIP code.in California and we'll continue now we.are at the applicant attorney.information page.we will go ahead and complete this.information note that email does not.have an asterisk next to it therefore it.is not mandatory for me to complete when.you get to the applicant attorney firm.name there's a tooltip it lets you know.that this for a name refers to your M's.uan you must have a M's uan to use this.system if not you need to register at.the DW c website once you register you.must wait at least 24 hours in order for.your firm name to appear on the list.this is very similar to the qme.specialty list where it shows the firm's.in alphabetical order or you can type a.letter of the alphabet and once you.choose it it'll populate the information.for you you can continue now we are at.the employer and claims administrator.page.I did that on purpose if you can see the.phone number will Auto format for you if.you enter too many numbers you will get.an error message letting you know that.you type too many digits let's try that.again.the email again is optional so I will.leave that blank for Claims.Administrator company name again this is.your Ames UI n so let's choose the Eames.uan for this insurance carrier now we.continue now we are at the defense.attorney information page if you notice.there are no asterisks next to these.fields because this page is optional the.reason why is because the applicant.attorney was the one who initiated this.form if the applicant attorney or Claims.Administrator initiates this form the.defense attorney information is optional.but for purposes of this demonstration.we'll go ahead and fill it out when you.get to the defense attorney firm name.again remember this is your Ames UI n.the system populates the information for.you and we can continue now we're at the.declaration confirmation page this page.has two statements for the user to.affirm it is to acknowledge that the.information provided is true incorrect.and the other is to agree to serve the.panel form the panelists and uploaded.documents to all parties within one.business day these two are requirements.in order for you to proceed in the form.if you don't you will receive an error.this error will let you know that the.certification of both the penalty of.perjury an agreement to serve the qme.panel and all parties is a mandatory.step of the online qme request process.if you have any questions you are to.contact the medical unit let's go ahead.and affirm both statements now we are at.the upload document page here is where.you can upload either the letter of.objection or the request for.compensability exam please note this.must be in either a PDF or TIFF format.and there's also a size limit of 10.megabytes.once you add your file you'll see it in.a blue link next to file attached now we.can continue now we're at the review and.submit page here you are able to review.all the inputs that you entered.throughout the forum if you need to make.any edits you can go to that specific.section by utilizing the blue link next.to this section header or you can use.the top row page button to get back to.that portion of the form everything.looks good we're gonna go ahead and.submit now we have a panel.as you can see this is very similar to.the paper panels that are currently.issued this is not the last step of the.process so we're going to go ahead and.continue now we are at the Declaration.of service page please note this page is.provided to you as a courtesy if there.is a declaration of service that your.company or firm would prefer to use.please do so as you can see the system.has pre-populated the relevant parties.for you you also have the opportunity to.add additional parties once this.information is completed we'll get our.document package now we are at the qme.panel document print page this is the.last step of the form it lets you know.again what your panel number is and.gives you three attachments the first is.the issued qme panel and declaration of.service the next is the qme form 106.which shows you all your form inputs and.the last is a copy of the supporting.document that you uploaded to review.these you can click on the icon and it.will bring it up for you to either print.or save to your local computer.there are also two links located at the.bottom one will take you back to the.medical unit home page and the other.will take you back to the beginning of.the forum to do another request if.necessary now that I have shown you how.to successfully submit and receive an.online panel I would like to show you a.few scenarios that will result in an.eligibility notice there are three.reasons why your request will be.rejected the first is you submitted a.duplicate request the second is you did.not observe the appropriate waiting.period before submitting a request and.the third is there are not enough queue.Emmys in the specialty requested first I.will show you what happens when you.submit a duplicate request I will be.using the same information that I used.earlier except I will have the defense.attorney request this panel.after I've completed and submitted the.form I'm presented with this page it.lets us know that the medical unit is.unable to fulfill my request because.there was already a panel issued for.this case as you can see it shows you.the three doctors that were previously.issued if you have any questions you can.contact the medical unit.the next example of an in eligibility.notice or rejection is for a request.submitted too early the system produced.this notice because the user did not.observe the appropriate waiting period.before submitting the request for an.online panel the last example of an an.eligibility notice or rejection is for.cases when there are not enough queue.Emmys for the specialty requested if you.encounter this notice you may contact.the medical unit for assistance for.additional information or if you have.any questions you may either visit the.do WC website at www.uvu.edu/library.

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QME Form 121 State Of California Dir Ca FAQs

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