Administrative Director Division of Workers' Compensation - Medical Unit P.O. Box 71010 Oakland, CA 94612 Section 1 (FOR ALL APPLICANTS) (Completion of these fields is required) PLEASE TYPE OR PRINT LEGIBLY Last Name First Name MI Suffix REAPPOINTMENT APPLICATION AS QUALIFIED MEDICAL EVALUATOR Contact Address (Use license board contact address) Business Phone (Use Area Code then the number ) (Required) Business- E-mail Address (optional) City State Zip Code California Professional License Number (Required) License Expiration Date (MM/DD/YYYY) (Required) Year Entered Practice(YYYY)(Required) Section 2 (FOR M.D.'s AND D.O.'s ONLY) APPLICANT MUST MEET ONE OF THE FOLLOWING REQUIREMENTS appointment, you must attach a copy of the certificate of board certification.) Specialty or subspecialty certification 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. (If you became board certified after your last QME Expiration Date (mm/dd/yyyy) Specialty or subspecialty certification Expiration Date (mm/dd/yyyy) Specialty or subspecialty certification Expiration Date (mm/dd/yyyy) Specialty or subspecialty certification Expiration Date (mm/dd/yyyy) 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 deemed to be equivalent to board certification in a specialty. (Please submit documentation from the Medical or Osteopathic Board.) Specialty or subspecialty certification Expiration Date (mm/dd/yyyy) Specialty or subspecialty certification Expiration Date (mm/dd/yyyy) 4) I was an active qualified medical evaluator on June 30, 2000. Section 3 (FOR ALL APPLICANTS) 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: (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.) 2. I have served as an Agreed Medical Evaluator (AME) on eight (8) or more occasions in the12 months prior to submitting this application. (Submit documentation of 8 AME cover letters, first page of reports or a sworn statement made under penalty of perjury.) 3. 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.) 4. 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. 5. I am retired from active practice due to a documented medical or physical disability as defined by Government Code §12926 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.) Section 4 (FOR ALL APPLICANTS) (FOR ALL APPLICANTS) PLEASE INDICATE THE SPECIALTY(IES) FOR WHICH YOU ARE APPLYING TO DO QME EXAMS-USE ENCLOSED REFER TO ATTACHED SPECIALTY CODES Professional practice specialty code (Required) Professional practice specialty code QME Form 104 (rev. 9/2015) Professional practice specialty code Professional practice specialty code Page 1 Section 5 (FOR ALL APPLICANTS) Affirmations: (Initialing each box affirms that you have read and agree to each of the statements. Do not 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. ) 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.) INITIALS B. Convictions. I certify that I have never been convicted of a misdemeanor or a felony related to my practice, or for a crime of moral turpitude. I agree to promptly notify the DWC Medical Unit of any future practice-related conviction, or conviction for a crime of moral turpitude. (Do not initial if either statement is untrue. Attach an explanation on a separate piece of paper. Convictions expunged under Penal Code § 1203.4 must be disclosed.)Do not initial if either statement is untrue. Attach an explanation on a separate piece of paper. ) C. Prohibited Activities. I agree that I shall abide by all Administrative Director regulations. 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 that 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 done a QME evaluation. Section 6 (FOR ALL APPLICANTS) Continuing Education Courses (Li