Form 104 - Reappointment Application As Qualified Medical Evaluator - Department Of Industrial Relations Industrial Medical Council, State Of California

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REAPPOINTMENT APPLICATION AS QUALIFIED MEDICAL EVALUATOR
For the Department of Industrial Relations
Industrial Medical Council
P. O. Box 8888
San Francisco, CA 94128-8888
BLOCK 1
(FOR ALL APPLICANTS)
PLEASE TYPE OR PRINT LEGIBLY
Please list your primary location. Additional locations may be added when your fee assessment is paid.
LAST NAME
FIRST NAME
MI
JR/SR
BUSINESS ADDRESS FOR QME EVALUATIONS
(DO NOT USE P. O. BOX)
CITY
ZIP
+
4
MAILING ADDRESS FOR CORRESPONDENCE
CITY
ZIP
+
4
(AREA CODE) PHONE NO.
(MM/YY)
CAL. PROFESSIONAL
YEAR ENTERED
EXPIRATION
LICENSE NUMBER
PRACTICE
PROCEED TO BLOCK 2
BLOCK 2 (FOR MDs AND DOs ONLY)
NOTE: APPLICANT MUST MEET ONE OF THE FOLLOWING REQUIREMENTS
T
F
(TRUE)
(FALSE)
1) I am board certified in the specialty for which I am applying to become a QME by a board recognized by
the Council and the Medical Board of California or the Osteopathic Medical Board of California. Date board
certification expires, if applicable___________________.
(If you became board certified after your last QME application, you must attach a copy of the certificate of
board certification).
2) I am board qualified because:
a) Since 1985, I have not failed the specialty certifying exam in the specialty for which I seek
-appointment as a QME; and
b) I have completed the minimum requirements as defined by a specialty board recognized by the Council
for postgraduate training in the specialty at an institution recognized by the ACGME or the osteopathic
equivalent on ___________________ . (Date Completed)
3) I declare under penalty of perjury to the Council that I wrote 100 or more ratable comprehensive medical-
legal evaluation reports and served as an AME on 25 or more occasions during each calendar year between
January 1, 1990, and December 31, 1994. (Please provide documentation of 25 AMEs between January 1,
1994 and December 31, 1994, i.e. AME cover letters or first page of the reports), if you have not already
done so.
I have submitted these documents previously.
4) I have qualifications that the Council and the Medical Board of California or the Osteopathic Medical
Board of California both deem to be equivalent to board certification in a specialty. (Please submit docu-
mentation from the Medical Board).
5) I declare under penalty of perjury to the Council that I served as an AME on 8 or more occasions
prior to 1/1/70.
PROCEED TO BLOCK 3
IMC FORM 104 Rev. 4/14/00

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