Free QME Disclosure of Specified Financial Interests Form – Download Now
The QME Disclosure of Specified Financial Interests form is required for Qualified Medical Evaluators (QMEs) in California to disclose any financial interests that could impact the fairness of a QME panel. This form must be submitted when completing QME Form 100, 103, or 104.
Why is QME Disclosure of Specified Financial Interests Form important?
This disclosure form helps maintain fairness and transparency in worker’s compensation evaluations by identifying potential conflicts of interest. If a QME has a financial rwlationship that could influence their medical-legal evaluation, they may be disquualified from serving on panel.
What Is a Specified Financial Interest?
A Specified Financial Interest includes:
- Owning 5% or more of a medical practice or healthcare facility.
- Being a general or limited partner in a medical business.
- Receiving profit shares from a medical practice.
- Holding loans, leases, or financial ties with a health-related facility.
- Having an indirect relationship with a healthcare provider.
QMEs must disclose these interests to ensure unbiased medical evaluations.
Who Needs to File This Form?
- All QMEs submitting Form 100, 103, or 104.
- Physicians applying for initial QME appointments or reappointments.
- QMEs updating their financial interest disclosures.
Template Categories
California
General
How to Use This Template
- Download the free template by typing in your email address in this page.
- Get the template directly in your inbox.
- Fill out all sections with accurate details about the accident and injuries.
- Share with your attorney or insurance company to support your claim.
Download the Free QME Disclosure of Specified Financial Interests Form
Ensure compliance with California Division of Workers’ Compensation (DWC) regulations by downloading the required QME Disclosure of Specified Financial Interests Form for free.
Download and complete your form today!
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