Qme Form 100 - Application For Appointment As Qualified Medical Evaluator
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FOR DWC USE ONLY
QME NO.:_________________
INPUT DATE:______________
INPUT BY:________________
APPLICATION FOR APPOINTMENT AS QUALIFIED MEDICAL EVALUATOR
Administrative Director
Division of Workers’ Compensation-Medical Unit
P.O. Box 71010
Oakland, CA 94612
SECTION 1 (FOR ALL APPLICANTS COMPLETION OF THIS FIELD IS REQUIRED) PLEASE TYPE OR PRINT LEGIBLY
Please list your primary location. DO NOT USE P.O. BOX. Office locations may be added when your fee assessment is paid. You will be billed shortly after
passing the QME test.
Last Name
First Name
MI
Suffix
Contact Address
(Use licensing board contact address)
City
State
Zip + 4
California Professional
Business Phone (Use Area Code
Business- E mail Address
License Expiration Date
Year Entered Practice
License Number (Required)
and number ) (Required)
(optional)
(MM/DD/YYYY) (Required)
(YYYY)(Required)
SECTION 2 (FOR ALL APPLICANTS) IMPORTANT: This section must be fully completed before proceeding.
PROFESSIONAL
EDUCATION INDICATE DEGREE OBTAINED (e.g. M.D., D.O., D.C., Ph.D., Psy.D., Ed.D., etc.) COLLEGE, UNIVERSITY OR MEDICAL SCHOOL
Country
Date of Degree
City
State
Degree
SECTION 3 (FOR M.D.’s AND D.O.’s ONLY) POSTGRADUATE TRAINING NOTE: For M.D.s or D.O.s who are not board certified, state law
requires successful completion of a residency training program accredited by the Accreditation Council for Graduate Medical Education or the American
Osteopathic Association. DO NOT ENTER “SEE RESUME”.
Type
RESIDENCY: Name of sponsoring institution
City
State
From
To
Type
RESIDENCY: Name of sponsoring institution
From
To
City
State
Type
Fellowship: Name of sponsoring institution
City
State
To
From
Indicate whether you are certified by a specialty board recognized by the Medical Board of California or the Osteopathic Medical Board of
California or have qualifications deemed to be equivalent to board certification in a specialty by the Medical Board of California or the
Osteopathic Medical Board of California .
Specialty or subspecialty certification
Expiration Date
Specialty or subspecialty certification
Expiration Date
Specialty or subspecialty certification
Expiration Date
Specialty or subspecialty certification
Expiration Date
IMPORTANT: IF THE M.D. OR D.O. IS BOARD CERTIFIED, PLEASE PROVIDE COPY OF BOARD CERTIFICATE(S). OTHERWISE, PLEASE PROVIDE
COPY OF CERTIFICATE(S) OF COMPLETION OF POSTGRADUATE TRAINING.
SECTION 4 (FOR M.D.s AND D.O.s ONLY)
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.
2) I completed postgraduate training in the specialty at an institution recognized by the ACGME or the American Osteopathic
Association.
3) 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 documentation from the Medical or
Osteopathic Board.)
QME Form 100 (rev. 9/2015)
Page 1
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