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BLOCK 8 (FOR ALL APPLICANTS)

PLEASE INDICATE SPECIALTY(IES) FOR WHICH YOU ARE APPLYING TO DO QME EXAMS (USE ENCLOSED SPECIALTY CODE LIST)

Professional practice

specialty code:

Reminder: For MDs & DOs, a copy of Board Certification or documentation of completion of a training program

accredited by the American College of Graduate Medical Education or the Osteopathic equivalent must

be submitted. For DCs, a certificate from postgraduate specialty diplomate program must be submitted

for each specialty.

PROCEED TO BLOCK 9

BLOCK 9 (FOR ALL APPLICANTS, IF COMPLETED)

I have completed a medical-legal report writing course approved by the IMC.

Course:

Date:

PROCEED TO BLOCK 10

BLOCK 10 (FOR ALL APPLICANTS)

INITIAL

EACH BOX

AFFIRMATIONS: Initialling each box affirms that you have read and agree to

each of the statements.

License Status

A. My license to practice medicine is active and is neither restricted nor encumbered by suspension, interim

suspension or probation. I certify that I have not been convicted of either a misdemeanor or felony related

to my practice or a crime of moral turpitude.

B. I agree to notify the Industrial Medical Council if my license to practice medicine is placed on suspension,

interim suspension, probation or is restricted by my licensing agency. I further agree to notify the Industrial

Medical Council if I am convicted of a misdemeanor or felony related to my practice or a crime of moral

turpitude. I understand that the IMC may deny my application or conditionally accept my application if my

license is on probation with my licensing authority.

Financial Interest

C. I agree that I shall abide by all IMC regulations. I will not refer patients to facilities in which I or my family

members have a financial interest, except as permitted by law. I agree I shall not offer, deliver, receive or

accept any rebate, refund, commission, preference, patronage, dividend, discount or other consideration,

whether in the form of money or otherwise, as compensation or inducement for any referred evaluation

or consultation. I agree not to solicit to provide medical treatment to an injured employee for any injury

for which I have done a QME evaluation. I have not performed a QME evaluation prior to certification

as a QME by the IMC.

VERIFICATION

I have used all reasonable diligence in preparing and completing this application. I have reviewed this completed application and

to the best of my knowledge the information contained herein and in the attached supporting documentation is true, correct and

complete. Failure to provide truthful information shall result in denial of applicants appointment and/or disciplinary action.

I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.

Executed on

(MM/DD/YY)

County

Applicant’s Signature

IMC FORM 100 (Rev.12.00)

Imc Form 100 - Application For Appointment As Qualified Medical Evaluator - California Department Of Industrial Relations Page 3

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