Reappointment Application As Qualified Medical Evaluator - California Division Of Workers' Compensation Page 4

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A PUBLIC DOCUMENT
PRIVACY NOTICE - The Information Practices Act of 1977 and the Federal Privacy Act require the Administrative Director to
provide the following notice to individuals who are asked by a governmental entity to supply information for appointment as a
Qualified Medical Evaluator (QME).
The principal purpose for requesting information from QMEs is to administer the QME program within the California workers'
compensation system. Additional information may be requested if your application is denied and/or a disciplinary action is
taken.
The California Labor Code requires every QME physician to meet certain statutory requirements. Physicians are required by
the Labor Code to provide: name; business address/addresses; professional education; training; license number; year entered
practice and other requirements deemed necessary by the Administrative Director. It is mandatory to furnish all the appropriate
information requested by the Administrative Director. Failure to provide all of the requested information may result in the denial
of the application.
As authorized by law, information furnished on this form may be given to: you, upon request; the public, pursuant to the Public
Records Act; a governmental entity, when required by state or federal law; to any person, pursuant to a subpoena or court
order or pursuant to any other exception in Civil Code § 1798.24.
An individual has a right of access to records containing his/her personal information that are maintained by the Administrative
Director. An individual may also amend, correct, or dispute information in such personal records (Civil Code § 1798.34-
1798.37).
Requests should be sent to:
Division of Workers' Compensation-Medical Unit
P.O. Box 71010
Oakland, CA 94612
(510) 286-3700 or (800) 794-6900
Fax: (510) 622-3467
You may request a copy of the Division of Workers' Compensation policy and procedures for inspection of records at the
above address. Copies of the procedures and all records are ten cents ($0.10) per page, payable in advance. (Civil Code §
1798.33).
QME Form 104 (rev. February 2009)
Page 4

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