QME Form 104 – Reappointment Application as a Qualified Medical Evaluator
The Reappointment Application as Qualified QME (QME Form 104) is a much-required document for physicians in California seeking to renew their position as a Qualified Medical Evaluator (QME). This form ensures that QMEs can continue to conduct medical-legal evaluations for workers’ compensation cases, maintaining compliance with the California Division of Workers’ Compensation (DWC) regulations.
Purpose of QME Form 104
The QME Form 104 is used to:
- Renew QME designation for physicians whose appointment period is ending.
- Ensure compliance with DWC requirements for medical-legal evaluations.
- Maintain eligibility to perform independent medical evaluations in workers’ compensation cases.
Failure to submit Form 104 on time may result in the removal of a physician from the QME panel, affecting their ability to conduct workers’ compensation evaluations.
Who Needs to Use QME Form 104?
This form must be completed by:
- Currently appointed QMEs seeking reappointment.
- Physicians who wish to continue providing medical-legal evaluations for workers’ compensation claims
New applicants or those who have lost their QME status must follow a separate application process.
How to Complete and Submit QME Form 104
- Download the form from the California DWC website or use the provided template.
- Complete all required sections, including personal details, medical license information, and specialty.
- Attach necessary documentation, such as proof of continuing education credits (if required).
- Submit the form by the deadline specified by the DWC Medical Unit.
Why Is QME Form 104 Important?
Submitting QME Form 104 on time is essential for physicians who want to continue conducting QME evaluations. This process ensures that all QMEs remain qualified and meet the necessary standards to assess workers’ compensation cases fairly and accurately.
Template Categories
California
General
How to Use the Template?
- Click the download button on this page.
- Enter your email to receive the form.
- Download and fill out the form with the necessary details.
- Submit the completed form.
Download the QME Form 104 Template for Free
Get your free QME Form 104 template to ensure a smooth reappointment process and maintain your Qualified Medical Evaluator status.
Download now and continue providing expert medical-legal evaluations in California’s workers’ compensation system!
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