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Application For Appointment As Qualified Medical Evaluator QME 100 - California
| Application For Appointment As Qualified Medical Evaluator Form. This is a California form and can be used in General Workers Comp . |
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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 BLOCK 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. Additional 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 JR/SR Business Address (where QME Evaluations will Take Place) City State Zip + 4 Mailing Address for Correspondence, if different City State Zip + 4 Business Phone (Include Area Code ) Business- Electronic Mail Address (optional) California Professional License Number (Required) License Expiration Date (MM/DD/YYYY) (Required) Year Entered Practice BLOCK 2 (FOR ALL APPLICANTS) IMPORTANT: BLOCK 2 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 City State Country Date of Degree Degree BLOCK 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. Fellowships will not be accepted in lieu of accredited residency training. DO NOT ENTER "SEE RESUME". PGY 1 or INTERNSHIP: Hospital/Facility City Type State From To RESIDENCY: Hospital/Facility City Type State From To RESIDENCY: Hospital/Facility City Type State From To RESIDENCY: Hospital/Facility City Type State From To RESIDENCY: Hospital/Facility City Type State From To IMPORTANT: IF APPLICANT IS BOARD CERTIFIED, PLEASE PROVIDE COPY OF BOARD CERTIFICATE(S). OTHERWISE, PLEASE PROVIDE COPY OF CERTIFICATE(S) OF COMPLETION OF POSTGRADUATE TRAINING. QME Form 100 (rev. 1/1/2013) Page 1 American LegalNet, Inc. www.FormsWorkFlow.com BLOCK 4 (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.]). BLOCK 5 (FOR Ph.D.'s, Psy.D.'s AND Ed.D.'s ONLY) NOTE: APPLICANT MUST MEET ONE OF THE FOLLOWING REQUIREMENTS (check one) 1) I am board certified in clinical psychology by the American Board of Professional Psychology and have at least five (5) years or more years post-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 at least five years post-doctoral experience diagnosis and treatment of emotional and mental disorders. 3) I have at least five years post-doctoral experience in the diagnosis and treatment of emotional and mental disorders and I have served as an Agreed Medical Evaluator (AME) on eight (8) or more occasions prior to January 1, 1990. (Please provide documentation of 8 AMEs, e.g. AME cover letters, first page of each report, or a sworn statement made under penalty of perjury.) BLOCK 6 (FOR M.D.'s AND D.O.'s ONLY) NOTE: APPLICANT MUST MEET ONE OF THE FOLLOWING REQUIREMENTS (check one) 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.) BLOCK 7 (FOR ALL APPLICANTS) NOTE: APPLICANT MUST MEET ONE OF THE FOLLOWING REQUIREMENTS (check one) 1) I devote at least one-third of my total practice time to providing direct medical treatment (Direct Medical Treatment is the 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. (Please provide documentation of 8 AMEs, e.g. AME cover letters, first page of each report, or a sworn statement made under penalty of perjury.) BLOCK 8 (FOR ALL APPLICANTS) PLEASE INDICATE THE SPECIALTY(IES) FOR WHICH YOU ARE APPLYING TO PERFORM QME EXAMS-USE ENCLOSED SPECIALTY CODE LIST. Professional practice specialty code Professional practice specialty code Professional practice specialty code BLOCK 9 (FOR ALL APPLICANTS, IF COURSE COMPLETED) I have completed a disability evaluation report writing course approved by the Administrative Director Course Date of Course BLOCK 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.) A. License Status and Convictions (Present and past) My California license to practice as a physician is active and is neither restricted nor encumbered by suspension, interim suspension or probation. I certify that I have not been convicted of either a misdemeanor or felony related to my practice or for a crime of moral turpitude. B. License Status and Convictions (Future changes) I agree to notify the Administrative Director if my California license to practice is placed on suspension, interim suspension, probation or is restricted by my licensing agency. I further agree to notify the Administrative Director if I am convicted of a misdemeanor or felony related to my practice or a crime of moral turpitude. I understand that the Administrative Director may deny my application or conditionally accept my application if my license is on pro
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