QME Appointment ONLINE

State of California Division of Workers' Compensation-Medical Unit QME Appointment Notification Form; Kambiz Hannani, MD

Please complete this form and we will call you/email you within 24 hours with time and date of appointment. Please call the office if you do not get contacted within 24 hours or you have any other questions. Thank you.
Employee Information (Completion of this section is required)
Patient's Name*

First NameMiddle NameLast Name
Patient Date of Birth

MonthDayYear
Date
Phone Number*
Address*

Employee Street Address

Street Address Line 2

Employee CityState

Postal / Zip Code
Date of injury [injuries]:*
Have you seen Dr. Hannani Before? [Is this a re-evaluation]:

YESNO
Please List ALL body Parts being claimed
Panel Number*
Claim or Case Number*
Employer Information
Employer Name*
Address

Employer Street Address

Street Address Line 2

Employer CityState / Province

Postal / Zip Code
Claims Administrator Information (Completion of this section is required)
Claims Administrator Name (Insert the name of the person handling the claim)*
Phone number*

Area CodePhone Number
Claim administrators company name:*
Address*

Claims Administrator Street Address

Street Address Line 2

Claims Administrator CityState / Province

Postal / Zip Code
Appointment Information (Completion of this section is required)
Date of appointment call:*

MonthDayYear
Date
Date of Appointment:*

MonthDayYear
Date
Time of appointment:*
QME address location as LISTED ON THE PANEL REQUEST*
Is Certified Interpreter required?*

YesNo
If an interpreter is required, indicate language:
Location of QME
Location of QME
QME Name:
NOTE:
APPLICANT ATTORNEY INFORMATION [if patient is represented]
Applicant attorney:

First NameLast Name
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
DEFENSE ATTORNEY INFORMATION [if carrier is represented]
Defense attorney:

First NameLast Name
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Name of individual completing this form

First NameLast Name
Email
example@example.com
Phone Number

Area CodePhone Number
Signature

Clear
Please verify that you are human*
Should be Empty:

State of California Division of Workers' Compensation-Medical Unit QME Appointment Notification Form; Kambiz Hannani, MD

Employer Information