QME Disclosure Of Specified Financial Interests {QME 124}

QME Form 124 - QME DISCLOSURE OF SPECIFIED FINANCIAL INTERESTS (“SFI Form 124” Attachment to QME Form 100, 103 & 104). This form is an attachment required for Qualified Medical Evaluator applications and reappointments in the California workers’ compensation system. The form requires physicians to disclose any specified financial interests, including partnership interests, ownership or profit interests of 5% or more, or entitlement to 5% or more of profits from medical practices, groups, clinics, or other entities that provide treatment or evaluation services in the system. Physicians must list associated business entities, addresses, and participating providers. The disclosure is signed under penalty of perjury to confirm accuracy and compliance with 8 CCR §29(b). www.FormsWorkflow.com