REAPPOINTMENT APPLICATION AS QUALIFIED MEDICAL EVALUATOR
Administrative Director
Division of Workers’ Compensation - Medical Unit
PRINT CLEAR
P.O. Box 71010
Oakland, CA 94612
BLOCK 1 (FOR ALL APPLICANTS)
PLEASE TYPE OR PRINT LEGIBLY
Please list your primary location. DO NOT USE P.O. BOX. Additional locations may be added when your fee assessment is
paid.
LAST NAME
FIRST NAME
MI
JR/SR
BUSINESS ADDRESS (WHERE QME EVALUATIONS WILL TAKE PLACE)
CITY
ZIP
+
4
MAILING ADDRESS FOR CORRESPONDENCE, IF DIFFERENT
CITY
ZIP
+
4
BUSINESS PHONE
BUSINESS EMAIL
CAL. PROFESSIONAL
EXPIRATION
(AREA CODE)
(OPTIONAL)
LICENSE NUMBER
(MM/YY)
PROCEED TO BLOCK 2
BLOCK 2 (FOR M.D.’s AND D.O.’s ONLY)
YES
NO
NOTE: APPLICANT MUST MEET ONE OF THE FOLLOWING REQUIREMENTS
1)
I am board certified in the specialty for which I am applying to become a QME by a board
recognized by the Administrative Director 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 have completed the minimum requirements as defined by a specialty board recognized
by the Administrative Director for postgraduate training in the specialty at an institution
recognized by the ACGME or the American Osteopathic Association
on_______________. (Date Completed.)
3) I was an active qualified medical evaluator on June 30, 2000.
4)
I have qualifications that the Administrative Director 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 supporting documentation.)
SUBMIT SUPPORTING DOCUMENTATION and PROCEED TO BLOCK 3
QME Form 104 (rev. February 2009)
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