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Free QME Form 100 Template – Apply to Become a Qualified Medical Evaluator

Download the QME Form 100 template for free. Use this form to apply for certification as a Qualified Medical Evaluator (QME) in California workers’ compensation cases.

Free Download

The Application for Appointment as Qualified Medical Evaluator (QME) – Form 100 is required for physicians who want to become a Qualified Medical Evaluator (QME) in California workers' compensation cases. A QME is a licensed physician who evaluates injured workers and provides medical-legal reports on workers' compensation claims.

Why Use QME Form 100?

This form is used to apply for QME certification with the California Department of Industrial Relations (DIR). Completing this application is the first step in becoming a state-approved medical evaluator.

Who Can Use This Form?

Licensed physicians (MD, DO, DC, DPM, OD, etc.)

Healthcare professionals eligible under California regulations

Those seeking certification as a QME in workers’ compensation cases

How to Use QME Form 100

Download the template for free from this page by providing your email address.

Get the form directly in your email inbox.

Download and fill out the required details, including your personal information, medical license number, education, and experience.

Submit the completed form to the DIR for review and approval.

Prepare for additional requirements, such as an exam or supporting documentation.

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