|Agreed Medical Evaluation
Regarding: Applicant: ________________________________________________
Date(s) of injury: __________________________________________
Case Number(s): ___________________________________________
The below signed parties agree to the following doctor as an agreed medical evaluation (AME).
An appointment for the examination of the applicant has been scheduled with the doctor as follows:
Date of appointment: _________________________________
Time of appointment: _________________________________
Telephone Number: _________________________________
The parties agree that the doctor is to conduct a thorough medical examination and prepare a comprehensive medical report in conformance with the requirements of Labor Code §4628.
The doctor is to complete a Findings Summary form (IMC Form 1002) and serve the completed form and the medical report on all parties and the Disability Evaluation Unit (DEU).
The doctor is to address all issues and consider all of the individual's complaints and symptoms that are attributed according to the individual to any alleged injury or injuries that are within the scope of the AME’s expertise.
The parties agree that they will not communicate with the AME other than by joint letter. The applicant is permitted to communicate with the AME for the purpose of the examination.
The parties have agreed upon information that shall be provided to the AME as required by Labor Code §4062.2(a). The parties will prepare a list of all documents that are to be given to the AME. This List of Agreed Documents must be signed by all parties. Any document on the List of Agreed Documents that has not been served upon a party must be served upon the party prior to that party approving the List of Agreed Documents.
By signing the List of Agree Documents the parties do not adopt or agree to any of the facts, opinions or findings contained in the documents. The parties are only agreeing that the AME is to review only those documents listed.
The AME is to review and rely upon only records and reports that have been agreed upon by the parties and listed in List of Agreed Documents. The AME is to identify in the report all information received from the parties, all information reviewed in preparation of the report, and all information relied upon in the formulation of any opinions in accordance with Board Rule §4062.2(d) If the AME desires any additional information in order to render a complete and thorough report, the AME is to request the information by a letter to all parties.
A copy of the claim form or forms and all applications for adjudication for each injury alleged by the employee are to be given to the AME.
The AME is authorized to refer to any medical text, treatises, periodicals and other source materials that have not been specifically prepared for this case.
The AME is authorized to conduct or order whatever diagnostic tests deemed necessary.
The AME’s findings and opinions are to be limited to his or her specialty. The AME is authorized to consult with other physicians in any appropriate specialty who are qualified medical evaluators when reasonably necessary, or to consult with a physician who is not a qualified medical evaluator, regardless of whether or not the physician is licensed to practice in California, only if the physician possesses necessary expertise in a specialty which the AME does not normally treat and without which a complete and accurate formal medical evaluation cannot be obtained1. Only one comprehensive medical report from the AME is requested. The AME is to review and incorporate any findings by consulting physicians into the AME’s report.
The AME is to render an opinion to a reasonable medical probability on the following issues:
Causation of Injury. The parties indicate below by checking the appropriate box whether the AME is to render an opinion as to causation of the injury.
Liability for the injury(s) has been admitted. The cause of the injury is not in dispute. The AME is not to address the issue of cause of the injury. See below for issue as to cause of disability (apportionment). If the AME does give an opinion regarding the cause of the injury the parties agree that the opinion of the AME on this issue will be disregarded.
One or more of the parties have not admitted liability for the injury(s). The AME is to render an opinion as the whether the employee’s medical treatment and disability, if any, was caused by, contributed by, or aggravated by the injury or injuries or industrial exposure as alleged in the application(s) for adjudication.
Permanent and Stationary. A disability is considered permanent when the employee has reached maximal medical improvement, meaning his or her condition is well stabilized, and unlikely to change substantially in the next year with or without medical treatment2. For each injury alleged the AME is to determine if the employee is permanent and stationary.
If the AME is able to determine a date that the employee became permanent and stationary, without speculating, the AME is to specify the date and give the reasons for choosing that date. If there is more than one injury alleged, the AME is to determine the permanent and stationary date for each separate injury alleged unless all injuries became permanent and stationary at the same time.
If the AME’s determination as to the permanent and stationary date differs from that of the primary treating physician’s, the AME is to indicate the reasons and the evidence relied upon as to why the primary treating physician’s opinion should not be adopted as permanent and stationary date.
Temporary Disability. If the AME determines that the employee is permanent and stationary, the AME is to state for each injury alleged all periods for which the employee was totally temporarily disabled.
Permanent Disability. The AME shall determine the percentage of permanent impairment. In determining the percentages of permanent impairment, account shall be taken of the nature of the physical injury or disfigurement. The "nature of the physical injury or disfigurement" shall incorporate the descriptions and measurements of physical impairments and the corresponding percentages of impairments published in the American Medical Association (AMA) Guides to the Evaluation of Permanent Impairment (5th Edition)3.
Work Restrictions and Preclusions. The AME is to determine the effect of any permanent disability upon the individual’s diminished future earning capacity by describing all work restrictions, limitations and preclusions.
Medical Treatment. The AME is to state what medical care, treatment and diagnostic studies are reasonably required at the present time to cure or relieve the effects of the injury or injuries. Please state, in as much detail as possible, what continuing or fixture medical care, treatment, medication and surgical procedures should be provided or made available and specify the duration.
Contribution. If the employee's medical condition was the result of more than one injury, including specific and continuous injuries, the AME is to give an opinion as to the amount each injury or period of continuous injury has contributed to the employee's disability, if any.
Causation of Disability (Apportionment). Effective April 19, 2004, apportionment of permanent disability shall be based on causation. Furthermore any physician who prepares a report addressing permanent disability due to a claimed industrial injury is required to address the issue of causation of the permanent disability in order for a permanent disability report to be complete, the report must include an apportionment determination. The determination shall be made pursuant to Labor Code section 4663 and 4664. The text of Labor Code section 4663 is set forth below:
(a) Apportionment of permanent disability shall be based on causation.
(b) Any physician who prepares a report addressing the issue of permanent disability due to a claimed industrial injury shall in that report address the issue of causation of the permanent disability.
(c) In order for a physician's report to be considered complete on the issue of permanent disability, it must include an apportionment determination. A physician shall make an apportionment determination by finding what approximate percentage of the permanent disability was caused by the direct result of injury arising out of and occurring in the course of employment and what approximate percentage of the permanent disability was caused by other factors both before and subsequent to the industrial injury, including prior industrial injuries. If the physician is unable to include an apportionment determination in his or her report, the physician shall state the specific reasons why the physician could not make a determination of the effect of that prior condition on the permanent disability arising from the injury. The physician shall then consult with other physicians or refer the employee to another physician from whom the employee is authorized to seek treatment or evaluation in accordance with this division in order to make the final determination.
(d) An employee who claims an industrial injury shall, upon request, disclose all previous permanent disabilities or physical impairments.
Apportionment of permanent disability can be caused by “other factors both before and subsequent to the industrial injury, including prior industrial injuries,” provided it can be demonstrated by substantial medical evidence that the non-industrial factors have caused permanent disability4. A medical report is not substantial evidence unless it sets forth the reasoning behind the physician’s opinion, not merely his or her conclusions and meets the requirements of Escobedo vs. Marshalls.5
Vocational Rehabilitation. The AME is to determine if the employee's permanent disability as the result of the injury or injuries, whether or not combined with the effects of a prior injury or disability permanently precludes, or is likely to preclude, the employee from engaging in his or her usual occupation or the position in which he or she was engaged at the time of injury.
The AME is to address the report to the Disability Evaluation Unit at the appropriate Workers' Compensation Appeals Board and serve the medical report, the summary and the billing statement on all of the parties. Billing is to be at ML 104 94 and 93.
The parties further agree that if, after the AME’s report is served, it becomes necessary to cross-examine the AME it will be done by deposition in the AME’s office in accordance with Board Rule § 10727, or the parties may prepare a subsequent joint letter with specific questions promulgated by the parties either separately or jointly, and request a supplemental report.