Intake Forms

Please download and complete the appropriate form according to the type of appointment being requested:

Our QME/AME Coordinator Valerie can be reached through the following:

Direct Line: (925) 273-9915

Direct Fax: (925) 241-4660


To avoid delay in scheduling a QME or AME evaluation, we require our intake to be filled out completely and forwarded to the scheduling coordinator. This applies to new appointments and re-evaluations. For initial QME evaluations, please attach panel letter. 

QME/AME Information

Call Us:  +1.925.461.2840


QME/AME Policies

Christopher Chen, M.D., Inc. 

* We recommend keeping a copy of these intakes on file for future appointment request.

- Notification of Appointment -

Notification of appointment and a copy of these disclaimers/ QME/AME policies are provided to the parties listed on the proof of service. We receive the information (names, addresses, fax numbers, etc.) from the rescheduling party and use that information to complete the proof of service. If they are inaccuracies in the proof of service or any documentation for the QME/AME evaluation, please notify the office immediately.

- Failure to Appear -

Appointment must be cancelled no later than two weeks prior to scheduled appointment. Failure to appear (patient or interpreter) will result in a no show fee of $500.00. The party scheduling appointment is informed written and verbally of our cancellation policy at the time of the appointment is scheduled.

- Cancellations -

ONLY the scheduling party may cancel an QME/AME appointment. Written documentation must be provided to cancel an appointment; verbal request are not accepted nor confirmation an appointment has been cancelled.

- Medical Records -

To provide you with timely reports, we require records to be sent a minimum of 2 weeks prior to the scheduled appointment. If records are not received at least 72 hours prior to the scheduled appointment, the appointment may be rescheduled and a no show fee charged. If you are requesting our office to return medical records, you must provide a shipping label with the appropriate postage. We do not return records unless clearly noted in cover letter.

- Unrepresented

If you are unrepresented, we request that all communication with our office be limited to written correspondences by mail or fax in order to avoid potential 'ex parte' communication conflicts. REMEMBER: 20 days prior to sending the letter to the AME/QME, you must first send a copy to the claims administrator.  


ATTN: Medical Records

4439 Stoneridge Drive, Suite 110, Pleasanton, CA 94588