How to Complete and Mail QME Form 105: Attachments, Service, and Panel Steps

QME Form 105 is the form an unrepresented California worker uses to ask the Division of Workers’ Compensation (DWC) Medical Unit for a panel of three Qualified Medical Evaluators when a medical issue in the claim is in dispute. There is no filing fee. You mail the completed form, a Proof of Service, and the required attachment to the Medical Unit’s P.O. Box in Oakland, and you mail a copy to the claims administrator the same day.

Who Can Use Form 105

Form 105 is only for injured workers who do not have an attorney. If you hire a lawyer at any point, your case moves to the represented panel process, which runs through a separate electronic system on the DWC website.¹ Form 105 is not available once you are represented.

You can file when a specific type of medical dispute has come up in your claim. The form lists four categories, and you check one:

Compensability: the claims administrator has denied your claim or disputes whether the injury is work-related, under Labor Code Section 4060.²
Treatment or disability dispute: you or the claims administrator objects to the treating physician’s determination about temporary disability, permanent disability, or future medical care, under Labor Code Sections 4061 and 4062.³
Additional body parts: the claim is accepted for one or more body parts, but whether to add others is in dispute.
Other non-treatment disputes: a catch-all for medical disagreements that do not fit above.

Either side can file. If both sides send in separate requests, the Medical Unit processes whichever arrives first.

Filling Out Page One

The form is a three-page PDF on the DWC website. Page one is the request, page two is the Proof of Service, and page three lists the specialty codes. Before you start, pull the denial letter or objection letter from the claims administrator. You will need to attach it.

The top of page one asks for your date of injury, claim number, and the medical specialty you want. Below that, check the box for the reason for the panel. The bottom half collects your name, mailing address, and zip code, your employer’s name, and the claims administrator’s contact information.⁴

The zip code controls geography. If you have moved out of California since the injury, use the California zip code where you lived on the date of injury. If you never lived in California, use a California zip code both parties have agreed on. The Medical Unit draws doctors from the area tied to that zip, so the choice is not cosmetic.

Sign and date page one at the bottom.

Picking the Specialty

The specialty you choose decides what kind of doctor evaluates you, and it is the most consequential choice on the form. Page three lists the codes in two groups: MD/DO specialties such as orthopedic surgery, neurology, psychiatry, and internal medicine, and non-MD/DO specialties, which include chiropractic and acupuncture. Pick one.⁵

Match the specialty to the actual medical issue. A back injury with disc problems usually points to orthopedic surgery. A head injury with cognitive symptoms points to neurology. Anxiety or depression tied to a workplace incident points to psychiatry or psychology. If your treating physician has recommended a specialist, follow that recommendation. A mismatched specialty produces a report that does not address the real dispute, and you are generally stuck with the panel once it issues.

If the Medical Director later concludes the specialty is medically inappropriate for the disputed issues, they can issue a replacement panel in the correct specialty.⁶ That takes a written request and review, so it is better to get it right the first time.

What to Attach

The attachment depends on why you are filing. Without the right one, the request may be delayed or rejected.

Compensability dispute: attach the claims administrator’s notice denying the claim, or the claims administrator’s request for a compensability evaluation.⁴
Objection to the treating physician’s report: attach the written objection. If the claims administrator filed the objection, that letter should identify the treating physician, the date of the report being disputed, and the medical issue in question.¹

If you do not have the letter you need, ask the claims administrator for a copy before you file.

Proof of Service and Mailing

Page two is a Proof of Service, and it is not optional. It documents that you sent a copy of the completed form to the claims administrator (or employer) on the same day you sent the original to the Medical Unit. You state your county of residence, confirm you are over 18, list the name and address of the party you served, and sign under penalty of perjury.⁴

Mail the completed Form 105, Proof of Service, and attachment to:

Division of Workers’ Compensation – Medical Unit
P.O. Box 71010
Oakland, CA 94612

The same day, mail a copy of the completed form to the claims administrator at the address on their correspondence. No filing fee applies.⁷ Keep copies of the signed form, the Proof of Service, the attachment, and any postal receipts.

What Happens After You Mail the Form

Once the Medical Unit has a properly completed request, it assigns a panel. You should receive the panel list within 20 business days. If it does not arrive in that window, you have the right to select any QME in the proper specialty from the DWC’s online QME database and schedule your own evaluation.⁷

The panel is a randomly generated list of three QME physicians in the specialty you asked for, drawn from the geographic area tied to the zip code on the form. You and the claims administrator receive the panel at the same time.⁸

Then a short clock starts. You have 10 days to pick one of the three doctors, call that office to schedule, and notify the claims administrator of your choice and the appointment date. All three steps happen inside the 10 days. Miss the deadline and the claims administrator gets to pick the doctor and set the appointment for you.⁹ This is one of the places unrepresented workers most often lose ground, because the QME’s report tends to drive the result of the whole claim.

If you are thinking about hiring an attorney, do it before you pick from the panel. Once a QME has examined you, you are generally bound by that doctor’s opinions even if you later get a lawyer.

When the Panel Does Not Work Out

Sometimes the panel is unusable, and California regulations list grounds for requesting a replacement QME or a new panel:

A doctor on the panel does not actually practice in the specialty you requested.
A QME cannot schedule the exam within 90 days of the initial appointment request, or 120 days if the 90-day limit was waived.
You moved after the panel issued and before the evaluation.
Two doctors on the panel belong to the same medical group.
A QME on the panel is or was your primary treating physician for the injury in dispute.
A QME has a disqualifying financial or personal relationship with a party to the case.

To request a replacement, complete DWC Replacement Panel Request Form 31.5 and mail it to the Medical Unit at the same Oakland P.O. Box used for Form 105, with a copy to the claims administrator.⁶ Replacements are not automatic. The Medical Director, and in disputed cases the Workers’ Compensation Appeals Board, decides whether the circumstances justify a new panel.

If the QME examines you but fails to produce a timely report, you have a separate statutory right to a replacement under Labor Code Section 4062.5.

1
Department of Industrial Relations. California Code of Regulations Title 8 Section 30 – QME Panel Requests
2
Justia. California Labor Code Sections 4060-4068
3
California Legislative Information. California Labor Code LAB 4061
4
Division of Workers’ Compensation. Request for Qualified Medical Evaluator Panel – QME Form 105
5
Division of Workers’ Compensation. How to Request a Qualified Medical Evaluator If You Do Not Have an Attorney
6
Department of Industrial Relations. California Code of Regulations Title 8 Section 31.5 – QME Replacement Requests
7
New York Codes, Rules and Regulations. California Code of Regulations Title 8 Section 108 – The Qualified Medical Evaluator Panel Selection Instruction Form
8
Division of Workers’ Compensation. Answers to Frequently Asked Questions About Qualified Medical Evaluators for Injured Workers
9
Department of Industrial Relations. California Code of Regulations Title 8 Section 31.3 – Scheduling Appointment with Panel QME