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Reappointment Application As Qualified Medical Evaluator QME 104 - California
| Reappointment Application As Qualified Medical Evaluator Form. This is a California form and can be used in General Workers Comp . |
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REAPPOINTMENT APPLICATION AS QUALIFIED MEDICAL EVALUATOR Administrative Director Division of Workers' Compensation - Medical Unit P.O. Box 71010 Oakland, CA 94612 BLOCK 1 (FOR ALL APPLICANTS) 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. LAST NAME FIRST NAME MI JR/SR BUSINESS ADDRESS (WHERE QME EVALUATIONS WILL TAKE PLACE) CITY ZIP + 4 MAILING ADDRESS FOR CORRESPONDENCE, IF DIFFERENT CITY ZIP + 4 BUSINESS PHONE (AREA CODE) BUSINESS EMAIL (OPTIONAL) CAL. PROFESSIONAL LICENSE NUMBER EXPIRATION (MM/YY) PROCEED TO BLOCK 2 BLOCK 2 (FOR M.D.'s AND D.O.'s ONLY) NOTE: 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. Date board certification expires, if applicable:___________________. (If you became board certified after your last QME application, you must attach a copy of the certificate of board certification.) I have completed the minimum requirements as defined by a specialty board recognized by the Administrative Director for postgraduate training in the specialty at an institution recognized by the ACGME or the American Osteopathic Association on_______________. (Date Completed.) YES NO 2) 3) I was an active qualified medical evaluator on June 30, 2000. 4) 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 supporting documentation.) SUBMIT SUPPORTING DOCUMENTATION and PROCEED TO BLOCK 3 QME Form 104 (rev. February 2009) Page 1 American LegalNet, Inc. www.FormsWorkflow.com BLOCK 3 (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 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.) 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 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.) 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. I am retired from active practice due to a documented medical or physical disability as defined by Government Code ยง12926 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.) 2) 3) 4) 5) SUBMIT SUPPORTING DOCUMENTATION and PROCEED TO BLOCK 4 BLOCK 4 (FOR ALL APPLICANTS) PLEASE INDICATE SPECIALTY(IES) FOR WHICH YOU ARE APPLYING TO DO QME EXAMS. (PLEASE USE SPECIALTY CODE LIST ATTACHED TO THIS FORM.) Professional practice specialty code Professional practice specialty code Professional practice specialty code PROCEED TO BLOCK 5 QME Form 104 (rev. February 2009) Page 2 American LegalNet, Inc. www.FormsWorkflow.com BLOCK 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.) INITIAL EACH BOX 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 take disciplinary action or may deny my application for reappointment if my license is on probation with my licensing authority. C. Referrals, Specified Financial Interests, Other Prohibited Activities I agree that I shall abide by all Administrative Director regulations. I have read and understand Labor Code Sections 139.3 and 139.31. I agree that I shall abide by all their provisions. 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 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
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