What this form is for
Request For QME panel under Labor Code Section 4062.1 - Unrepresented
Official file
Published by the Division of Workers' Compensation. This page does not replace the form — it points at the state's PDF and, where the form is what a panel actually ruled on, quotes that ruling.
How to fill a DWC form →Source: dir.ca.gov/dwc/forms.html. Unofficial guide — the PDF on that site is the form.
What the Appeals Board did with this
Decisions of the Workers' Compensation Appeals Board that turned on this kind of filing. Each quotes the passage it turned on and links to the official PDF.
- ADJ13039423 · 2026-06-01 · Anaheim District OfficeQME/AME processdefendant prevailed
Determinative passage · p.10Dr. Betancourt's reports contained thorough and detailed discussions of the issues presented. His opinions and conclusions were framed in terms of reasonable medical probability, were not speculative, and were based on pertinent facts and documents and on an adequate examination and history. Dr. Betancourt also thoroughly set forth his reasoning in support of his conclusions. Based thereon, Dr. Betancourt's opinions constitute substantial medical evidence upon which the Court can rely.
The court found no good cause to disqualify Dr. Betancourt, as his opinions were based on reasonable medical probability and substantial evidence.
Official decision · page 10 → - ADJ20106865 · 2026-05-18 · Pomona District OfficeQME/AME processapplicant prevailed
Determinative passage · p.7Not only does the letter not explicitly refer to objection, it does not contain any objection whatsoever. Applicant is entitled to retain the control of the QME process and did nothing to lose that control. Thus, defendant waived its right to an objection.
Defendant's strike letter did not contain any objection to the QME panel specialty, so defendant waived its right to object; applicant was entitled to choose the specialty and chiropractic was appropriate.
Official decision · page 7 → - ADJ20938147 · 2026-04-30 · Pomona District OfficeQME/AME processapplicant prevailed
Determinative passage · p.6Here, defendant's notice of delay was served on May 23, 2025 within California on applicant by regular mail. (Exhibit A.) The parties were therefore required to wait until fifteen (15) days after May 23, 2025, or until the after 5:00 p.m. on June 9, 2025 before requesting a panel. In their panel request, however, defendant indicated that the "date of request for comprehensive exam" was May 22, 2025. (Exhibit B, p. 3.) This is contrary to the facts of the case and contrary to the parties' stipulation to a May 23, 2025 "start date per Labor Code 4062.2." (Minutes of Hearing and Summary of Evidence (MOH & SOE), February 2, 2026, p. 2.) We therefore conclude that considering defendant's usage of an incorrect date, defendant's QME panel request was invalid. Accordingly, the issuance of panel 7823574 is similarly invalid.
Defendant's QME panel request was premature due to incorrect date usage, making the panel invalid and entitling applicant to a replacement chiropractic panel.
Official decision · page 6 → - ADJ17870859 · 2026-04-23 · Lodi District OfficeQME/AME processapplicant prevailed
Determinative passage · p.9Given the above, we find that a QME in the specialty of neurology (MPN) to address the applicant's post-concussion headaches, post-concussion syndrome and closed head injury, as well as any industrial causation of same, is appropriate.
The WCAB found good cause for an additional neurology panel based on Dr. Chow's recommendation, applicant's symptoms, and the stipulation of treating physician Dr. Lin reporting headaches, despite defendant's objection to industrial causation.
Official decision · page 9 →