Qme Form 100 - Application For Appointment As Qualified Medical Evaluator Page 3

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INITIALS

D. I have not performed a QME evaluation prior to appointment as a QME by the Administrative Director. I have accurately and fully

reported all specified financial interests that may affect the fairness of QME panels, as required on the attached QME SFI Form 124.

Verification I have used all reasonable diligence in preparing and completing this application. I have reviewed this completed application and

to the best of my knowledge the information contained herein and in the attached supporting documentation is true, correct and complete.

I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. (Failure to provide truthful

information shall result in denial of applicant’s appointment and/or disciplinary action.)

Executed on:

State

Applicant's signature

IMPORTANT: Your application for appointment as a QME shall be returned if it is incomplete. Please check:

That your application is fully completed, dated and signed with an original signature. We will not accept faxed applications.

All necessary documentation is attached:

All applicants: A Copy of your current California Professional License.

M.D.’s, D.O.’s: A copy of your board certificate(s) and certificate(s) completion of residency and fellowship training program(s)

by the Accreditation Council for Graduate Medical Education or the American Osteopathic Association.

Please provide a copy for each specialty in which you are requesting appointment to perform QME Exams.

D.C.’s: A copy of your certificate in California Workers' Compensation Evaluation .

Ph.D.’s, Psy.D.’s and Ed.D.’s: A copy of your professional diploma(s). A copy of board certification, if appropriate.

ALL OTHERS: A copy of your professional diploma(s) and California License.

A copy of the completion certificate from the report writing course is required by title 8 Cal. Code Regs. §11.5,

once completed. This document must be submitted prior to obtaining your appointment as a QME.

g) A completed, signed QME SFI Form 124. (QME Disclosure of Specified Financial Interests That May Affect the

Fairness of QME Panels. This document must be submitted prior to obtaining your appointment as a QME.

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 QME’s 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 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

Tel: (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 100 (rev. 9/2015)

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