Fillable APPLICATION FOR APPOINTMENT AS QUALIFIED MEDICAL EVALUATOR Administrative (California)

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APPLICATION FOR APPOINTMENT AS QUALIFIED MEDICAL EVALUATOR Administrative (California)

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Page 1
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 Zip + 4
Business Phone (Use Area Code
and number ) (Required)
Business- E mail Address
(optional)
California Professional
License Number (Required)
License Expiration Date
(MM/DD/YYYY) (Required)
City State
Date of Degree
Degree
RESIDENCY: Name of sponsoring institution
To
State
City
To
State
City
RESIDENCY: Name of sponsoring institution
To
State City
Fellowship: Name of sponsoring institution
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.
State
From
From
From
Country
Year Entered Practice
(YYYY)(Required)
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 .
Expiration DateSpecialty or subspecialty certification Expiration DateSpecialty or subspecialty certification
Expiration Date Expiration Date
Type
Type
Type
QME Form 100 (rev. 9/2015)
Specialty or subspecialty certification
Specialty or subspecialty certification
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
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”.
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.)
SECTION 4 (FOR M.D.s AND D.O.s ONLY)
NOTE: APPLICANT MUST MEET ONE OF THE FOLLOWING REQUIREMENTS
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Page 2
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.)
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 6 (FOR D.C.’s ONLY)
NOTE: APPLICANT MUST MEET THE FOLLOWING REQUIREMENT
QME Form 100 (rev.9/2015)
Professional practice specialty code
Professional practice specialty code
Professional practice specialty code
SECTION 8 (FOR ALL APPLICANTS) PLEASE INDICATE THE SPECIALTY(IES) FOR WHICH YOU ARE APPLYING TO DO QME EXAMS-
REFER TO ATTACHED SPECIALTY CODES
Date of Course
Course
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
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 5 (FOR Ph.D.’s, Psy.D.’s AND Ed.D.’s ONLY) NOTE: APPLICANT MUST MEET ONE OF THE FOLLOWING
REQUIREMENTS
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.
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. )
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. )
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
Professional practice specialty code (Required)
Executed on:
at
State
,
Applicant's signature
Page 3
QME Form 100 (rev. 9/2015)
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.)
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.
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.
f) 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.
e) ALL OTHERS: A copy of your professional diploma(s) and California License.
d) Ph.D.’s, Psy.D.’s and Ed.D.’s: A copy of your professional diploma(s). A copy of board certification, if appropriate.
c) D.C.’s: A copy of your certificate in California Workers' Compensation Evaluation .
b) 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.
a) All applicants: A Copy of your current California Professional License.
2) All necessary documentation is attached:
1) That your application is fully completed, dated and signed with an original signature. We will not accept faxed applications.
IMPORTANT: Your application for appointment as a QME shall be returned if it is incomplete. Please check:
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.
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.
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).
A PUBLIC DOCUMENT
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).
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
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).
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.
INITIALS
Page 4
For Use on the QME Application Form 100
IMPORTANT: PLEASE USE THREE LETTER SPECIALTY CODE WHEN COMPLETING BLOCK 8 OF APPLICATION FORM
MD/DO SPECIALTY CODES
MAI Allergy & Immunology MHH Orthopaedic Surgery - Hand
MAA Anesthesiology MTO Otolaryngology
MPA Pain Medicine MHA Pathology
MDE Dermatology MPR Physical Medicine & Rehabilitation
MAI Dermatology - Allergy & Immunology
MPA Physical Medicine & Rehabilitation - Pain Medicine
MEM Emergency Medicine MPS Plastic Surgery (other than Hand)
MTT Emergency Medicine - Toxicology MHH Plastic Surgery - Hand
MFP Family Medicine MPD Psychiatry (other than Pain Medicine)
MPM General Preventive Medicine MPA Psychiatry - Pain Medicine
MTT General Preventive Medicine - Toxicology MSY Surgery (other than Spine or Hand)
MMM Internal Medicine MHH Surgery - Hand
MAI Internal Medicine - Allergy & Immunology MSG Surgery - General Vascular
MMV Internal Medicine - Cardiovascular Disease MTS Thoracic Surgery
MME Internal Medicine - Endocrinology Diabetes & Metabolism MUU Urology
MMG Internal Medicine - Gastroenterology
NON-MD/DO SPECIALTY CODES
MMH Internal Medicine - Hematology ACA Acupuncture
MMI Internal Medicine - Infectious Disease DCH Chiropractic
MMO Internal Medicine - Medical Oncology DEN Dentistry
MMN Internal Medicine - Neurology OPT Optometry
MMP Internal Medicine - Pulmonary Disease POD Podiatry
MMR Internal Medicine - Rheumatology PSY Psychology
MPN Neurology
MPA Neurology - Pain Medicine
MNS Neurological Surgery (other than Spine)
MNB Neurological Surgery - Spine
MOG Obstetrics & Gynecology
MOQ Medicine Otherwise Qualified
MPO Occupational Medicine
MTT Occupational Medicine - Toxicology
MOP Ophthalmology
MOS Orthopaedic Surgery (other than Spine or Hand)
MNB Orthopaedic Surgery- Spine
QME Form 100 (rev. 9/2015)
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APPLICATION FOR APPOINTMENT AS QUALIFIED MEDICAL EVALUATOR Administrative (California)

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Completed 7 April 2021

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