QME Form

APPLICANT INFORMATION

Applicants Name

DOB

RepresentedUnrepresented

Address

Phone

SSN#

Date of Injury

Panel#

Claim/Case#

WCAB/EIMS#

EMPLOYER INFORMATION:

Name

Address

Phone

Fax

CLAIMS ADMINISTRATOR (ADJUSTOR) INFORMATION:

Name

Company

Address

Phone

Fax

APPLICANT’S ATTORNEY (if, applicable):

Name

Company

Address

Phone

Fax

DEFENSE ATTORNEY (if, applicable):

Name

Company

Address

Phone

Fax

APPOINTMENT INFORMATION

Name of Person Scheduling Appointment

Please Specify Title

AdjustorApplicant AttorneyDefense AttorneyApplicant

QME Evaluator

Anish S. Shah MDNaga Kothapalli MD

Location of Appt

Interpreter Needed?

YesNo If yes, specify language needed

Type of Appointment Requested

Panel QMEAMEIMEAOE/COERe-Eval QME

Other