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Free QME Disclosure of Specified Financial Interests Form – Download Now

Download the QME Disclosure of Specified Financial Interests Form for free. Ensure compliance with California DWC regulations and maintain fairness in QME panels.

Free Download

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 the 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.

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