Location Fee Calculation Worksheet Form - State Of California - Department Of Industrial Relations

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STATE OF CALIFORNIA
GRAY DAVIS, GOVERNOR
DEPARTMENT OF INDUSTRIAL RELATIONS
INDUSTRIAL MEDICAL COUNCIL
ADDRESS REPLY TO:
Tel: (650) 737-2700 Fax: (650) 737-2989
P.O. Box 8888
San Francisco, CA 94128-8888
Date: _____________________________
Fee Period: _______________________
License Number: ___________________
Dear Dr______________________:
Pursuant to Labor Code § 139.2(n) and 8 CCR, § 16, the Industrial Medical
Council requires all physicians appointed or reappointed as Qualified Medical
Evaluators (QMEs) to pay an annual fee.
The QME fee is non-refundable.
$250 FEE
QMEs who have conducted 25 or more comprehensive medical - legal evaluations
in the twelve months prior to assessment of the fee.
All evaluations
performed as a Qualified Medical Evaluator, Agreed Medical Evaluator, and
Independent Medical Evaluator must be counted for the purposed of fee
assessment (8 CCR §§ 14, 15).
$125 FEE
QMEs who have conducted 11-24 comprehensive medical legal evaluations in the
twelve months prior to assessment of the fee. All evaluations performed as a
Qualified Medical Evaluator, Agreed Medical Evaluator, and Independent Medical
Evaluator must be counted for the purpose of fee assessment (8 CCR §§ 14, 15).
$110 FEE
QMEs who have conducted 0-10 comprehensive medical legal evaluations in the
twelve months prior to assessment of the fee.
All evaluations performed as a
Qualified Medical Evaluator, Agreed Medical Evaluator, and Independent Medical
Evaluator must be counted for the purpose of fee assessment (8 CCR §§ 14, 15).
ADDITIONAL LOCATIONS
QMEs who perform evaluations at more than one medical office location are
required to pay an additional $100 per location (8 CCR, § 15).
Misrepresentation of the number of evaluations performed or the number of
shall
additional locations
constitute grounds for disciplinary proceedings (8
CCR, §60).
1

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