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Qme Disclosure Of Specified Financial Interests

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State of California

Division of Workers’ Compensation Medical Unit

P.O. Box 71010

Oakland, CA 94612

QME DISCLOSURE OF SPECIFIED FINANCIAL INTERESTS

(“SFI Form 124” Attachment to QME Form 100, 103 & 104)

Name

Professional License No.

Business Address

QME No. (if applicable)

Business Telephone No.

Fax No.

PARTNERSHIP INTERESTS* (Attached continuation sheets of needed)

Name of Business Entity in which have limited or full partnership interest:

Address of Business Entity:

Names of partners who are physicians at same location (MD, DO, DC, OD, DPM, DDS, PhD or L.Ac.):

INTERESTS OF 5% OR MORE IN MEDICAL PRACTICE, MEDICAL GROUP OR OTHER MEDICAL

OR MEDICAL/LEGAL BUSINESS ENTITY IN CALIFORNIA WORKERS’ COMPENSATION SYSTEM*

Name of Medical Practice/Group/Business Entity:

Address of Business Entity:

Names of participating physicians at same location (MD, DO, DC, OD, DPM, DDS, PhD or L.Ac.):

RECEIPT OF 5% OR MORE OF PROFITS FROM MEDICAL PRACTICE, MEDICAL GROUP OR OTHER

MEDICAL OR MEDICAL/LEGAL BUSINESS ENTITY IN CALIFORNIA WORKERS’ COMPENSATION

SYSTEM*

Name of Medical Practice/Group/Business Entity:

Address of Business Entity:

Names of participating physicians at same location (MD, DO, DC, OD, DPM, DDS, PhD or L.Ac.):

I declare under penalty of perjury that the foregoing information is current, complete and accurate to the best of my knowledge.

Signed this _________ day of _________, 20____ at ________________, California.

Print name____________________________________________

Signature:_______________________________________________

* “Specified Financial Interests” means being a general partner or limited partner in, or having an interest of 5 percent or more, or receiving or being legally

entitled to receive a share of 5 % or more of the profits from, any medical practice, group practice, medical group, professional corporation, limited liability

corporation, clinic or other entity that provides treatment or medical evaluation, goods or services for use in the California workers’ compensation system. (8

Cal. Code Regs. § 29 (b).)

QME Form 124

rev. February 2009

Qme Disclosure Of Specified Financial Interests

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