Any physician who files a QME Form 100 (Application for Appointment), 103 (QME Fee Assessment Form) or 104 (Reappointment Application) with the Administrative Director also shall complete the QME SFI Form 124, in order to disclose specified financial interests that may affect the fairness of QME panels, and append it to the form 100, 103 or 104 being submitted when the form is filed.
Form is available at no charge by downloading from the web at www.dir.ca.gov/dwc/forms.html or by requesting at 1-800-794-6900.
Note: Authority cited: Sections 53, 133, 139.2 and 5307.3, Labor Code. Reference: Sections 139.2, Labor Code.
1. New section filed 1-13-2009; operative 2-17-2009 (Register 2009, No. 3).