REAPPOINTMENT APPLICATION AS QUALIFIED
MEDICAL EVALUATOR
Administrative Director
Division of Workers’ Compensation - Medical Unit
P.O. Box 71010
Oakland, CA 94612
Zip CodeStateCity
Contact Address (Use license board contact address)
SuffixMIFirst Name Last Name
Section 1 (FOR ALL APPLICANTS) (Completion of these fields is required) PLEASE TYPE OR PRINT LEGIBLY
License Expiration Date
(MM/DD/YYYY) (Required)
Business Phone (Use Area Code
then the number ) (Required)
Business- E-mail Address
(optional)
Year Entered
Practice(YYYY)(Required)
California Professional
License Number (Required)
Section 2 (FOR M.D.s AND D.O.s ONLY) 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. (If you became board certified after your last QME
appointment, you must attach a copy of the certificate of board certification.)
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 deemed to be equivalent to board certification in a specialty. (Please submit documentation from the Medical or
Osteopathic Board.)
4) I was an active qualified medical evaluator on June 30, 2000.
Section 3 (FOR ALL APPLICANTS) 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: (a) attempts to clinically diagnose and to alter or modify the
expression of a non-industrial illness, injury or pathological condition; or (b) 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 the12 months prior to submitting this
application. (Submit documentation of 8 AME cover letters, first page of reports or a sworn statement made under penalty of perjury.)
3. I am currently a salaried faculty member at an accredited university or college. I have a current California license to practice as a
physician and have been engaged in teaching, lecturing, published writing or medical research at that university or college in my area of
specialty for not less than one-third of my professional time. My practice in the three consecutive years immediately preceding the time of
application was not devoted solely to the forensic evaluation of disability. (Please submit evidence of your faculty appointment.)
4. I am retired from active practice. I have a minimum of 25 years’ experience in practice as a physician and, currently, I practice fewer
than 10 hours per week on direct medical treatment as a physician. My practice in the three consecutive years immediately preceding the
time of reappointment was not devoted solely to the forensic evaluation of disability.
5. I am retired from active practice due to a documented medical or physical disability as defined by Government Code §12926 and
currently practicing in my specialty fewer than 10 hours per week. I have 10 years’ experience in workers’ compensation medical issues as
a physician. My practice in the three consecutive years immediately preceding the time of application was not devoted solely to the
forensic evaluation of disability. (Please submit medical documentation of your disability.)
Professional practice specialty code
Professional practice specialty codeProfessional practice specialty code (Required)
Section 4 (FOR ALL APPLICANTS)
(FOR ALL APPLICANTS) PLEASE INDICATE THE SPECIALTY(IES) FOR WHICH YOU ARE
APPLYING TO DO QME EXAMS-USE ENCLOSED REFER TO ATTACHED SPECIALTY CODES
QME Form 104 (rev. 9/2015) Page 1
Professional practice specialty code
Expiration Date (mm/dd/yyyy)Specialty or subspecialty certification Expiration Date (mm/dd/yyyy)Specialty or subspecialty certification
Expiration Date (mm/dd/yyyy)Specialty or subspecialty certification
Expiration Date (mm/dd/yyyy)Specialty or subspecialty certification
Expiration Date (mm/dd/yyyy)Specialty or subspecialty certification Expiration Date (mm/dd/yyyy)Specialty or subspecialty certification
Reset Form
Print Form
Section 5 (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 explanation on a separate piece of paper. Failure to do so may result in disciplinary action by the Administrative
Director.) INITIALS
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 or a 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 6 (FOR ALL APPLICANTS) Continuing Education Courses (List the continuing education courses you have completed within
the last 24 months)
Provider Name
Course Name
Course Date (mm/dd/yyyy)
Credit hours
Credit hours
Course Date (mm/dd/yyyy)
Course Name Provider Name
Credit hours
Course Date (mm/dd/yyyy)
Course Name Provider Name
Applicant's signature
State
,
at
Executed on:
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.)
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 QMEs 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 or 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). 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:
Page 2
QME Form 104 (rev. 9/2015)
Division of Workers' Compensation-Medical Unit
P.O. Box 71010
Oakland, CA 94612
Phone (510) 286-3700 or (800) 794-6900
Fax: (510) 622-3467
QME Form 104 (rev. 9/2015)
Page 3
For Use on the QME Application Form 104
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 Practice MPD Psychiatry (other than Pain Medicine)
MPM General Preventive Medicine MPA Psychiatry- Pain Medicine
MTT General Preventive Medicine - Toxicology MHH Surgery - Hand
MMM Internal Medicine MSG Surgery - General Vascular
MAI Internal Medicine - Allergy & Immunology MTS Thoracic Surgery
MMV Internal Medicine - Cardiovascular Disease MUU Urology
MME Internal Medicine - Endocrinology Diabetes &
Metabolism
NON-MD/DO SPEICALTY CODES
MMG Internal Medicine - Gastroenterology ACA Acupuncture
MMH Internal Medicine - Hematology DCH Chiropractic
MMI Internal Medicine - Infectious Disease DEN Dentistry
MMO Internal Medicine - Medical Oncology OPT Optometry
MMN Internal Medicine - Nephrology POD Podiatry
MMP Internal Medicine - Pulmonary Disease PSY Psychology
MMR Internal Medicine - Rheumatology
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)