In an unrepresented case, if the IW does not have the Employee's Permanent Disability Questionnaire
(DWC-AD Form 100) - The QME office should provide the form to the IW
"Disability = Impairment + Loss earning capacity + Occupational title + Age" - Formula for PD
1911 - California adopted - The d...
QME Examination Test Questions FINAL
In an unrepresented case, if the IW does not have the Employee's Permanent Disability Questionnaire
(DWC-AD Form 100) - The QME office should provide the form to the IW
"Disability = Impairment + Loss earning capacity + Occupational title + Age" - Formula for PD
1911 - California adopted - The development of the State Compensation Insurance Fund (SCIF)
A check or Money Order is pain by the Physician for the IBR fee in the amount of - $195 ??
A copy of the notice to request time extension to file a QME report must be sent to - Medical Unit
at DWC
A local work comp Judge's decisions may be appealed by a part to - WCAB Commissioners
A PTP has fulfilled his or her reporting duties by sending ___ copy of a required report to the claims
administrator - one (1)
A trade-off between Employers and Employees is referred to as - The Historic Compromise
A violation of L.C. 139(a) conflict of interest referral is a misdemeanor subject to civil penalties up to
$____ per offense - $5,000
A worker who is nor represented by an attorney is referred to as - an unrepresented worker
An application for IBR (DWC form IBR-1) can be completed and submitted electronically by registering as
a user on the ___ IBR tracking system - Maximus Federal
An attorney or a court reporter may NOT be present at ___ exams - Psychiatric
An employer must report injuries to Cal/OSHA of any death or serious injury within _____ - 24
hours
An employer with an MPN which of the following CANNOT be pre-designated - D.C.
An injured worker may not be kept waiting for more than ___ after the scheduled appointment time -
one (1) hour
Apportionment is included in which of the following reports - PR-4
California passed its first workers' compensation act (voluntary) in ___ - 1911
California passed its first workers' compensation act after a devastating fire at the ____ in New York City
claimed the lives of 146 young workers - Triangle Shirtwaist Company
, In an unrepresented case, if the IW does not have the Employee's Permanent Disability Questionnaire
(DWC-AD Form 100) - The QME office should provide the form to the IW
Chronic Pain Guidelines went into effect ___ - 07/18/2009
Death benefits are payments to a spouse, the children, or other dependents, including reasonable burial
expenses, not exceeding $____ for injuries before 01/01/2013 and $_____ for injuries on or after
01/01/2013 - Before 01/01/2013 $5,000
After 01/01/2013 $10,000
Disputes over medical treatment for all dates of injury are now resolved by physicians through ____ -
IMR
Electronic bills are paid within ___ days of receipt of the bill and supporting documentation - 15
days
Employers are not required to pay for .... - Self Inflicted injuries
Ex Parte communication with an agreed Medical Evaluator or s QME selected from a panel .... - Is
PROHIBITED
Factors of Disability include the following - Subjective Factors
Objective Factors
Work Restrictions
Loss Pre-Injury Capacity
Failure to file a DFR could delay benefits to patients, prevent payment to physician, and could result in a
civil penalty of not less than $___ - $50
For a QME evaluation for compensability only (AOE/COE), DO NOT send the QME report to the following
Part(ies)? - Local DEU
For dates of injuyr AFTER 01/01/2005, a QME must use - American Medical Association Guide to
the Evaluation of Permanent Impairment, 5th edition
For DOI after 01/01/1990 or DOI after 01/01/2003, DISABLED MINORS receive benefits - For life
For DOI on or after 01/01/2005 the PTP final report must include the information on the ___ Form -
PR-4
For injuries on or after January 1, 1994 and before 01/01/2004 most workers will be limited to a _____
cap on Vocational Rehabilitation benefits under that plan - $16,000
For paper billing forms for health care providers, the physician must use - CMS 1500 forms
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