Arnold Schwarzenegger, Governor
STATE OF CALIFORNIA
DEPARTMENT OF INDUSTRIAL RELATIONS
INDUSTRIAL MEDICAL COUNCIL
P. O. Box 8888
San Francisco, CA 94128
Tel. No.: (650) 737-2700 or 1-(800) 794-6900
Fax No.: (650) 737-2711
QME/AME TIME FRAME EXTENSION REQUEST - (For Late Reporting on
Please send this form to the industrial Medical Council (IMC) at the above address 5 days before your report is due to
be served on the parties. Send a copy of this form to the employee and employer/insurer/claims administrator. The
QME may not be entitled to payment for evaluations which are not submitted in a timely manner (Labor Code § 4062.5).
If you need further information, please call us at (650) 737-2700 or 1-800-794-6900.
DATE OF EVALUATION: ___________________
DATE REPORT WILL BE SERVED: ________________
THERE ARE ONLY THREE (3) VALID REASONS FOR AN EXTENSION, YOU ARE REQUIRED TO CHECK ONE
OF THE THREE (3) BOXES LISTED BELOW. FORMS NOT FULLY COMPLETED WILL BE RETURNED.
REASON FOR REQUEST:
Lab/tests have not been completed - type of test(s) requested:_________________________________
Consulting specialist has not completed evaluation - type of specialist(s) requested:________________
For injuries between 1/1/91 and 12/31/93. If extension requested is beyond 90 days, from date of initial
evaluation, please attach justification.
For injuries on or after 1/1/94. If extension requested is beyond 60 days, from date of initial evaluation,
please attach justification
EXTENSIONS FOR GOOD CAUSE:
Extensions for Good Cause may not exceed an additional 15 days from the date the report is required to be served
and must be approved by the Administrative Director. Please check the appropriate box and specify good cause.
Medical emergency of the evaluator or the evaluator's family.
Death in evaluator's family.
Natural disaster or other community catastrophes that interrupt the operation of the evaluator's