California QME Form 110 is the Appointment Notification Form that a Qualified Medical Evaluator’s office completes and sends to all parties after scheduling a workers’ compensation medical-legal exam. The QME has five business days from the day the appointment is set to mail or fax it to you.1Department of Industrial Relations. California Code of Regulations Title 8 Section 110 – The Appointment Notification Form You don’t fill it out yourself — injured workers and claims administrators receive it. A blank copy lives on the DWC forms page at www.dir.ca.gov/dwc/forms.html, or you can request one by calling 1-800-794-6900.2Department of Industrial Relations. DWC Forms
What the Form Tells You, and What to Check
Form 110 is divided into five blocks pulled from the claim file and the panel selection letter issued by the DWC Medical Unit.3Division of Workers’ Compensation. QME Appointment Notification Form Read it carefully as soon as it arrives. Catching an error now is far easier than untangling one at the Workers’ Compensation Appeals Board later.
The employee block lists your name, address, phone, date of injury, the QME panel number from the Medical Unit’s panel letter, and the claim or case number. The panel number is worth double-checking. It links the evaluation to the specific panel the DWC issued, and a mismatch creates administrative problems down the line.
The employer and claims administrator blocks identify the employer and the adjuster handling your claim, with a contact name, phone, company, and mailing address. If the employer is self-insured and handling the claim directly, those two blocks may contain the same information.
The appointment block is the one that governs your day. It lists the date and time of the exam, the full examination address, and a separate address for where medical records should be sent (which can differ from the exam site if the QME reviews records at another office). It also indicates whether a certified interpreter is required and in what language.
The final block names the QME, lists the office address, and carries the QME’s signature and the date the form was signed.
Interpreter and Telehealth Notations
If you need a certified interpreter, the QME must note it on Form 110 and name the language. The interpreter is arranged by whichever party is responsible for the cost under Labor Code Section 5811.4Department of Industrial Relations. California Code of Regulations Title 8 Section 34 – Appointment Notification and Cancellation If the interpreter doesn’t show, the evaluation can’t go forward and the QME may charge a missed-appointment fee. Confirm the arrangement a few days ahead.
For a remote evaluation under Section 46.3 of Title 8, the injured worker, the claims administrator or employer, and the QME must all agree in writing, and the QME must attest in writing that no in-person physical exam is needed. The QME’s office listed on the original panel selection form is treated as the official evaluation site for administrative purposes.5Department of Industrial Relations. California Code of Regulations Title 8 Section 46.3 – Remote Health Medical-Legal Evaluations
Who Gets Served, and How
The QME’s office sends Form 110 to the injured worker and the claims administrator (or the employer directly, if none exists). In represented cases, it also goes to the attorneys on both sides, if known.3Division of Workers’ Compensation. QME Appointment Notification Form Service can be made by first-class mail or fax.4Department of Industrial Relations. California Code of Regulations Title 8 Section 34 – Appointment Notification and Cancellation A Declaration of Service at the bottom of the form records the sender’s address, the date of service, the method used, and each party served.
That five-business-day clock starts the day the appointment is set, not the day the panel request arrives at the QME’s office.6Cornell Law Institute. California Code of Regulations Title 8 Section 34 – Appointment Notification and Cancellation If you haven’t received a Form 110 after about a week, contact the QME’s office before the exam date sneaks up on you.
Cancellation Window and the Missed-Appointment Fee
Neither party, nor their attorney, may cancel or reschedule a QME appointment less than six business days before the appointment date without good cause.4Department of Industrial Relations. California Code of Regulations Title 8 Section 34 – Appointment Notification and Cancellation Cancellation timing is measured by postmark if mailed or by fax receipt date if faxed.
Cancel inside that six-day window without good cause and the QME may charge a missed-appointment fee of $503.75 under code ML200 of the Medical-Legal Fee Schedule. The same fee applies if the injured worker simply doesn’t appear, if the interpreter fails to show and the exam can’t proceed, if the worker leaves before the evaluation is finished, or if the worker arrives more than 30 minutes late and the QME can’t continue.7Department of Industrial Relations. California Code of Regulations Title 8 Section 9795 – Reasonable Level of Fees for Medical-Legal Expenses An injured worker who cancels for good cause is not liable for the fee.
When the Appointment Can’t Be Scheduled in Time
The evaluation must be scheduled within 90 days of the party’s initial appointment request. If nothing is available in that window, the requesting party can waive the right to a replacement QME and accept a date up to 120 days out. When the QME can’t schedule inside 120 days, either party can report the unavailability to the Medical Director and request a replacement QME, unless both sides agree in writing to waive the time limit.8Department of Industrial Relations. California Code of Regulations Title 8 Section 31.3 – Scheduling Appointment with Panel QME
Replacements are requested by filing QME Form 31.5 with the DWC Medical Unit.9Division of Workers’ Compensation. Replacement Panel Request The Medical Director selects a replacement QME at random, or, at the Director’s discretion, replaces the entire panel. Because starting over adds time to the case, parties sometimes prefer a written agreement to extend scheduling deadlines instead.
Keep the Form for Your Mileage Claim
Injured workers can claim mileage reimbursement from the claims administrator for travel to the evaluation. As of January 1, 2026, the rate is $0.725 per mile.10Division of Workers’ Compensation. DWC Workers’ Compensation Benefits File the claim using DWC Form 395, the Mileage Reimbursement Form. Keep your Form 110 — the examination address on it is what documents your round-trip distance.