Qme Form 100 - Application For Appointment As Qualified Medical Evaluator Page 2
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4SECTION 5 (FOR Ph.D.’s, Psy.D.’s AND Ed.D.’s ONLY)
NOTE: APPLICANT MUST MEET ONE OF THE FOLLOWING
REQUIREMENTS
1) I am board certified in clinical psychology by the American Board of Professional Psychology and have five (5) years doctoral
experience.
2) I have a doctoral degree in psychology, or a doctoral degree deemed equivalent for licensure by the Board of Psychology, from a
university or professional school recognized by the Administrative Director and have not less five than years postdoctoral
experience in the diagnosis and treatment of emotional and mental disorders.
3) I have not less than five years postdoctoral experience in the diagnosis and treatment of emotional and mental disorders and I have
served as an Agreed Medical Evaluator (AME) on eight or more occasions prior to January 1, 1990. (Please provide documentation
of 8 AMEs, i.e. AME cover letters, first page of the reports, or a sworn statement made under penalty of perjury.)
SECTION 6 (FOR D.C.’s ONLY)
NOTE: APPLICANT MUST MEET THE FOLLOWING REQUIREMENT
I am certified in California workers’compensation evaluation by either a California professional chiropractic association
or an accredited California college recognized by the Administrative Director (i.e. Industrial Disability Evaluation Certificate
[min. 44 hrs.]).
SECTION 7 (FOR ALL APPLICANTS)
NOTE: APPLICANT MUST MEET ONE OF THE FOLLOWING REQUIREMENTS
1) I devote at least one-third of my total practice time to providing direct medical treatment (direct medical treatment is that
special phase of the physician-patient relationship during which the physician: (1) attempts to clinically diagnose and to alter
or modify the expression of a non-industrial illness, injury or pathological condition; or (2) attempts to cure or relieve the effects of
an industrial injury.)
2) I have served as an Agreed Medical Evaluator (AME) on eight (8) or more occasions in the 12 months prior to submitting this
application. (Submit documentation of 8 AMEs, i.e. AME cover letters, first page of reports or a sworn statement made under
penalty of perjury.)
SECTION 8 (FOR ALL APPLICANTS)
PLEASE INDICATE THE SPECIALTY(IES) FOR WHICH YOU ARE APPLYING TO DO QME EXAMS-
REFER TO ATTACHED SPECIALTY CODES
Professional practice specialty code (Required)
Professional practice specialty code
Professional practice specialty code
Professional practice specialty code
SECTION 9
(FOR ALL APPLICANTS, IF COURSE COMPLETED) I certify that I have completed a disability evaluation report
writing course approved by the Administrative Director
Date of Course
Course
SECTION 10 (FOR ALL APPLICANTS) Affirmations: (Initialing each box affirms that you have read and agree to each of the
statements. Do not initial if your statement is untrue. Attach an explanation on a separate piece of paper.)
INITIALS
A. License Status. I certify that no disciplinary action has ever been taken against my California license to practice as a physician,
and that my license is active and neither restricted nor encumbered by suspension, interim suspension or probation. I agree to
promptly notify the DWC Medical Unit of any future disciplinary action taken against me by my licensing agency. (Do not initial if
either statement is untrue. Attach an explanation on a separate piece of paper. )
B. Convictions. I certify that I have never been convicted of a misdemeanor felony related to my practice, or for a crime of moral
turpitude. I agree to promptly notify the DWC Medical Unit of any future practice-related conviction, or conviction for a crime of
moral turpitude. (Do not initial if either statement is untrue. Attach an explanation on a separate piece of paper. Convictions
expunged under Penal Code § 1203.4 must be disclosed.)Do not initial if either statement is untrue. Attach an explanation on a
separate piece of paper. )
C. Prohibited Activities. I agree that I shall abide by all Administrative Director 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 that 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.
QME Form 100 (rev.9/2015)
Page 2
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