Deborah Sanders

 Paulette Cass, D.C., Q.M.E. 
 88 Belvedere Street, San Rafael, CA 89037
 April 21, 2014
 Karina Smith, Claims Examiner 
 Gallagher Bassett Services 
 P.O. Box 7003 
 Anaheim, CA 92825 
 Samuel Mullin, Esq. 
 Hodson & Mullin 
 601 Buck Avenue 
 Vacaville, CA 89037 
 Re: 
 Florintino Mejia 
 WCAB Number: 
 ADJ8510080 
 Panel Number: 
 1489037 
 Claim Number: 
 890376001366WC01 
 Date of Birth: 
 May 22, 1998
 Date of Injury: 
 April 18, 2017
 Employer: 
 Chevy's 
 Date of Evaluation: 
 February 19, 2017
 PANEL QUALIFIED MEDICAL EVALUATION 
 Dear Gentlepersons, 
 Thank you for the opportunity to evaluate Mr. Mejia in my Fairfield office on 4/11/2013. This 
 Qualified Medical Evaluation was performed with regards to Mr. Mejia's back. 
 Pursuant to 8 California Code of Regulations, Section 9795 (b) and (c), this report is submitted 
 as an ML104-95, Comprehensive Complex Medical-Legal Evaluation involving four or more 
 complexity factors 
 (1) Two or more hours of face-to-face time by the physician with the injured worker; 
 (2) Two or more hours of record review by the physician; 
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