Form 12210 - Notice Of Qme Unavailability - Department Of Industrial Relations Industrial Medical Council, State Of California
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1STATE OF CALIFORNIA
GRAY DAVIS, GOVERNOR
DEPARTMENT OF INDUSTRIAL RELATIONS
INDUSTRIAL MEDICAL COUNCIL
ADDRESS REPLY TO:
395 Oyster Point Blvd., Ste. 102
P.O. Box 8888
South San Francisco, CA 94080
San Francisco, CA 94128-8888
Tel: (650) 737-2700 Fax: (650) 737-2989
NOTICE OF QME UNAVAILABILITY
(
Form must be filed 30 days prior to date of unavailability)
TO:
Executive Medical Director
Industrial Medical Council
Please check the appropriate boxes, if you will be unavailable for panel assignment for a period of 14
days or more.
[ ] Please accept this notice that I will be unavailable for qualified
medical evaluation panel selection assignment:
from __________________________ to __________________________
(month, day, year)
(month, day, year)
[ ] Check here if you have filed for unavailability during the calendar year.
[ ] I will no longer be available for qualified medical evaluation assignment. Please
remove my name from the list of Qualified Medical Evaluators.
________________________________________________________________________________
[ ] The above information is for all of my QME office locations.
[ ] The above information is only for the QME office location(s) listed below.
QME Office Street Address: _________________________________________________________
City ___________________________________ CA
Zip ________________________________
QME Office Street Address: _________________________________________________________
City ___________________________________ CA
Zip _______________________________
QME Office Street Address: _________________________________________________________
City ___________________________________ CA
Zip ________________________________
________________________________________________________________________________
Signature ___________________________ Date ____________ License # ____________________
Name(print/type)_______________________________ Phone (_____)_______________________
NOTE: It is not an acceptable reason for unavailability that a QME does not intend to perform evaluations for unrepresented workers.
A QME who is unavailable may not perform QME evaluation until the QME has been reinstated. A QME who is unavailable for more
than 90 days during the calendar year without good cause may be denied reappointment.
___________________________________________________________________________________________________
Send this completed form to:
Industrial Medical Council
P. O. Box 8888
San Francisco, CA 94128-8888
IMC FORM 12210 (Rev.2/96)
Authority cited: Sections 139, 139.2, Labor Code. Reference: Sections 139.2, 4061, 4062, Labor Code
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