How to Fill Out California QME Form 31.5: Grounds, Attachments, and Filing

California QME Form 31.5 is the Replacement QME Request you file with the Division of Workers’ Compensation Medical Unit when a Qualified Medical Evaluator on your existing panel cannot serve. Complete the fillable PDF with your panel number, claim information, and the specific regulatory ground for replacement, attach any required medical reports, and mail it to the DWC Medical Unit in Oakland. The Medical Director then selects a replacement QME at random from the same specialty, or in some circumstances replaces the whole panel.¹

When Form 31.5 Applies

Form 31.5 is not how you request a QME panel in the first place. It is used only after a panel of three QMEs has already issued and a problem surfaces with one of the evaluators. The form works for both represented and unrepresented workers’ compensation cases, and it can be submitted by the injured worker, an attorney, or a claims administrator.

If no panel has issued yet, you need Form 105 (unrepresented workers) or Form 106 (represented cases) instead. Form 31.5 picks up only once a QME on the issued panel turns out to be unavailable, in the wrong specialty, or otherwise disqualified.

Grounds You Can Cite

The Medical Director will only grant a replacement for one of the reasons listed in 8 CCR § 31.5(a). Pick the one that fits your situation and mark it on the form:¹

A QME on the panel does not actually practice in the specialty you designated.
The QME cannot schedule an exam within 90 days of your initial appointment request. If you waived the 90-day limit under 8 CCR § 31.3(e), the window extends to 120 days; beyond that, either party can ask for a replacement.
The injured worker moved after the panel issued but before the initial evaluation.
Two QMEs on the panel belong to the same medical group.
The QME is unavailable under 8 CCR § 33, such as during a leave of absence or suspension.
The QME who previously reported in the case is no longer available to continue.
A panel QME is or was the worker’s primary treating physician or secondary physician for the disputed injury.
The parties agree in writing to receive a new panel keyed to the worker’s workplace address rather than home address.
Good cause based on a documented medical or psychological impairment related to the injury.
The Medical Director reviews the Doctor’s First Report (Form DLSR 5021) and the most recent progress report (DWC Form PR-2) and finds the chosen specialty does not fit the disputed medical issues.
The QME violated the appointment-notification and cancellation rules in 8 CCR § 34. This ground expires 15 days after the violation.

In represented cases, the form has an additional checkbox for a QME stricken during the Labor Code § 4062.2(c) striking process. Mark that box when the replacement is needed because one side struck a panel member.

Filling Out the Form

Download the current Form 31.5 from the DWC forms page at dir.ca.gov.² It is a fillable PDF, so type into it before printing. If you write by hand, use clear block letters. The Medical Unit returns incomplete or illegible forms, and each round trip adds weeks.

Identifying Information

The top of the form ties your request to the existing panel. The panel number is required; find it on the panel list letter the Medical Unit sent after your original Form 105 or 106 request. The claim number is also required and appears on correspondence from the claims administrator. Enter the EAMS case number only if a case has been filed with the Workers’ Compensation Appeals Board. The date of injury is required.

Parties and the QME to Be Replaced

Check whether the requesting party is the applicant’s side (injured worker or their attorney) or the defense side (claims administrator or defense attorney). Enter the employee’s first name, middle initial, and last name. If the worker is unrepresented, put the worker’s contact information in the applicant line; if represented, enter the attorney’s name and firm. Fill in the defense attorney or claims administrator name.

Enter the full name of the specific QME you want replaced. Then select the reason for replacement from the list on the form, matching one of the § 31.5(a) grounds above.

Requestor Details

At the bottom, enter your name, job title, phone number, full mailing address, and signature. Include the law firm or insurance carrier if you are filing on their behalf. Date the form the day you sign it.

Documents to Attach

Most grounds need nothing beyond the completed form. Two situations require extra paperwork:¹

Inappropriate specialty under § 31.5(a)(10): attach a copy of the Doctor’s First Report of Occupational Injury or Illness (Form DLSR 5021) and the most recent Primary Treating Physician’s Progress Report (DWC Form PR-2), or the narrative report filed in its place.
Workplace-area panel by agreement under § 31.5(a)(8): attach the signed written agreement between the claims administrator (or employer) and the employee.

For a good-cause request under § 31.5(a)(9), the regulation requires the impairment to be documented, so include the medical records that support it.

If your ground is a specialty-appropriateness challenge, review your treating physician’s records before filing so you can point to the specialty that actually fits the disputed condition. The DWC publishes the three-letter specialty codes for MD and DO physicians on its website, and a separate page lists non-MD/DO specialties such as chiropractic and psychology.³⁴

Where to Send It

Submit the completed form to the DWC Medical Unit in Oakland.⁵

Regular mail:
DWC – Medical Unit
P.O. Box 71010
Oakland, CA 94612

Certified mail, priority mail, or packages:
DWC – Medical Unit
1515 Clay Street, 18th Floor
Oakland, CA 94612

All packages, certified mail, and priority mail must go to the street address, not the P.O. Box. A tracked package sent to the P.O. Box may be delayed or returned. The Medical Unit phone number is (510) 286-3700, or toll-free at (800) 794-6900.

Keep copies of everything and use a method that provides proof of delivery. If the form is incomplete or the stated reason does not match a regulatory ground, the Medical Unit returns it with an explanation and the clock does not start until a corrected version arrives.

What Happens After You File

Once the Medical Unit accepts a valid Form 31.5, the Medical Director randomly selects a replacement QME from certified evaluators in the same specialty. Where the problem affects the panel’s integrity rather than a single evaluator, the Medical Director may replace the entire panel.¹

The regulation does not set a specific processing timeline. Mail-based requests take longer because of postal transit and manual review. If your case is time-sensitive, call the Medical Unit to confirm receipt and ask about turnaround.

Once the replacement name arrives, the usual scheduling rules apply. Unrepresented workers have ten days to select and contact the new QME and notify the claims administrator.⁶ In represented cases, the striking process under Labor Code § 4062.2(c) resumes with the updated panel.⁷ If the replacement QME also cannot schedule within 90 days, you can file another Form 31.5 citing the scheduling-delay ground again.

1
Department of Industrial Relations. California Code of Regulations Title 8 Section 31.5 – QME Replacement Requests
2
Division of Workers’ Compensation. DWC Forms
3
California Department of Industrial Relations. DWC Medical Unit – Areas of Expertise by QME Specialty for MD and DO Physicians Performing QME Evaluations
4
Division of Workers’ Compensation. Areas of Expertise by QME Specialty for Non-MD/DO
5
California Department of Industrial Relations. DWC Medical Unit
6
Department of Industrial Relations. California Code of Regulations Title 8 Section 31.3 – Scheduling Appointment With Panel QME
7
California Legislative Information. California Code LAB 4062.2 – Medical Evaluations in Represented Cases