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BLOCK 4 (FOR DCs ONLY)

NOTE: APPLICANT MUST MEET ONE OF THE FOLLOWING REQUIREMENTS

TRUE

FALSE

1) I am certified in California workers compensation evaluation by either a California professional chiropractic

association or an accredited California college recognized by the Council. (i.e. IDE Certificate (min. 44 hrs.

eff. 4/15/99).

2) I have completed a chiropractic postgraduate specialty program of a minimum of 300 hours taught by a school or

college recognized by the council, the Board of Chiropractic Examiners and the Council on Chiropractic Education.

PROCEED TO BLOCK 7

SUBMIT DOCS.

BLOCK 5 (FOR Ph.Ds, Psy.Ds AND Ed.Ds ONLY)

NOTE: APPLICANT MUST MEET ONE OF THE FOLLOWING REQUIREMENTS

TRUE FALSE

1) I am board certified in clinical psychology by the American Board of Professional Psychology, Inc.

2) I have a doctoral degree in psychology, or a doctoral degree deemed equivalent for licensure by the Board

of Psychology, from a university or professional school recognized by the Industrial Medical Council and

have not less than five years postdoctoral experience in the diagnosis and treatment of emotional and mental

disorders.

3) I have not less than five years postdoctoral experience in the diagnosis and treatment of emotional and mental

disorders and I have served as an (Agreed Medical Evaluator) AME on eight or more occasions prior to January

1, 1990. (Please provide documentation of 8 AMEs, i.e. AME cover letters, first page of the reports, or a sworn

statement made under penalty of perjury).

PROCEED TO BLOCK 7

SUBMIT DOCS.

BLOCK 6 (FOR MDs AND DOs ONLY)

NOTE: APPLICANT MUST MEET ONE OF THE FOLLOWING REQUIREMENTS

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.

2) I completed postgraduate training in the specialty at an institution recognized by the ACGME or the osteopathic

equivalent.

3) 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 documentation from the

Medical Board).

PROCEED TO BLOCK 7

SUBMIT DOCS.

BLOCK 7 (FOR ALL APPLICANTS)

NOTE: APPLICANT MUST MEET ONE OF THE FOLLOWING REQUIREMENTS

TRUE

FALSE

) I devote at least one-third of my total practice time to providing direct medical treatment (Direct Medical Treatment

is that special phase of the health care provider-patient relationship which (1) attempts to clinically diagnose and alter

or modify the expression of a non-industrial illness, injury or pathological condition; or (2) attempts to cure or relieve

the effects of an industrial injury.)

2) I have served as an Agreed Medical Evaluator (AME) on eight (8) or more occasions in the 12 months prior to

submitting this application. (Submit documentation of 8 AMEs, i.e. AME cover letters, first page of reports or a sworn

statement made under penalty of perjury.)

PROCEED TO BLOCK 8

IMC FORM 100 (Rev.12.00)

Imc Form 100 - Application For Appointment As Qualified Medical Evaluator - California Department Of Industrial Relations Page 2

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