Christine Hale

 Paulette Cass, D.C., Q.M.E. 
 88 Belvedere Street, San Rafael, CA 11089
 08-20-2022
 David Larsen, Claims Examiner 
 Gallagher Bassett Services 
 P.O. Box 7003 
 Anaheim, CA 92825 
 Samuel Mullin, Esq. 
 Hodson & Mullin 
 601 Buck Avenue 
 Vacaville, CA 11089 
 Re: 
 Florintino Mejia 
 WCAB Number: 
 ADJ8510080 
 Panel Number: 
 1411089 
 Claim Number: 
 110896001366WC01 
 Date of Birth: 
 10-02-1996
 Date of Injury: 
 09-12-2014
 Employer: 
 Chevy's 
 Date of Evaluation: 
 09-17-2021
 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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