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.

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.