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 SECTION 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. Office 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 Suffix Contact Address (Use licensing board contact address) City State Zip + 4 Business Phone (Use Area Code and number ) (Required) Business- E mail Address (optional) California Professional License Number (Required) License Expiration Date (MM/DD/YYYY) (Required) Year Entered Practice (YYYY)(Required) SECTION 2 (FOR ALL APPLICANTS) IMPORTANT: This section 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 SECTION 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. DO NOT ENTER "SEE RESUME". Type RESIDENCY: Name of sponsoring institution City State From To Type RESIDENCY: Name of sponsoring institution City State From To Type Fellowship: Name of sponsoring institution City State From To Indicate whether you are certified by a specialty board recognized by the Medical Board of California or the Osteopathic Medical Board of California or have qualifications deemed to be equivalent to board certification in a specialty by the Medical Board of California or the Osteopathic Medical Board of California . Specialty or subspecialty certification Expiration Date Specialty or subspecialty certification Expiration Date Specialty or subspecialty certification Expiration Date Specialty or subspecialty certification Expiration Date IMPORTANT: IF THE M.D. OR D.O. IS BOARD CERTIFIED, PLEASE PROVIDE COPY OF BOARD CERTIFICATE(S). OTHERWISE, PLEASE PROVIDE COPY OF CERTIFICATE(S) OF COMPLETION OF POSTGRADUATE TRAINING. SECTION 4 (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. 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.) American LegalNet, Inc. www.FormsWorkFlow.com QME Form 100 (rev. 9/2015) Page 1 SECTION 5 (FOR Ph.D.'s, Psy.D.'s AND Ed.D.'s ONLY) NOTE: APPLICANT MUST MEET ONE OF THE FOLLOWING REQUIREMENTS 1) I am board certified in clinical psychology by the American Board of Professional Psychology and have five (5) years 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 not less five than years postdoctoral experience in the diagnosis and treatment of emotional and mental disorders. 3) I have not less than five years postdoctoral experience in the diagnosis and treatment of emotional and mental disorders and I have served as an Agreed Medical Evaluator (AME) on eight or more occasions prior to January 1, 1990. (Please provide documentation of 8 AMEs, i.e. AME cover letters, first page of the reports, or a sworn statement made under penalty of perjury.) SECTION 6 (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.]). SECTION 7 (FOR ALL APPLICANTS) NOTE: 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: (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. (Submit documentation of 8 AMEs, i.e. AME cover letters, first page of reports or a sworn statement made under penalty of perjury.) SECTION 8 (FOR ALL APPLICANTS) PLEASE INDICATE THE SPECIALTY(IES) FOR WHICH YOU ARE APPLYING TO DO QME EXAMSREFER TO ATTACHED SPECIALTY CODES Professional practice specialty code (Required) Professional practice specialty code Professional practice specialty code Professional practice specialty code SECTION 9 (FOR ALL APPLICANTS, IF COURSE COMPLETED) I certify that I have completed a disability evaluation report writing course approved by the Administrative Director Course Date of Course SECTION 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.) INITIALS 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. ) B. Co