Reappointment Application As Qualified Medical Evaluator {QME 104}

QME Form 104 - REAPPOINTMENT APPLICATION AS QUALIFIED MEDICAL EVALUATOR. This form is used by physicians seeking renewal of their QME status within the California Division of Workers’ Compensation. The form collects essential licensing and practice information, including professional license details, years in practice, board certifications, specialty codes, and qualifying background under statutory and regulatory requirements. Applicants must confirm that they meet one of the eligibility paths—such as board certification, postgraduate specialty training, AME experience, faculty appointment, or limited practice due to retirement or disability. The form also requires attestations regarding license status, convictions, and prohibited activities, along with a list of recent continuing education courses. Applicants must sign under penalty of perjury and review the included privacy notice regarding information use. www.FormsWorkflow.com