Sandra Martin

 Paulette Cass, D.C., Q.M.E. 
 88 Belvedere Street, San Rafael, CA 11905
 01 November 2017
 Ronald Hudson, Claims Examiner 
 Gallagher Bassett Services 
 P.O. Box 7003 
 Anaheim, CA 92825 
 Samuel Mullin, Esq. 
 Hodson & Mullin 
 601 Buck Avenue 
 Vacaville, CA 11905 
 Re: 
 Florintino Mejia 
 WCAB Number: 
 ADJ8510080 
 Panel Number: 
 1411905 
 Claim Number: 
 119056001366WC01 
 Date of Birth: 
 13 January 2000
 Date of Injury: 
 05 September 2015
 Employer: 
 Chevy's 
 Date of Evaluation: 
 13 October 2022
 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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