QME Form 104 – Reappointment Application as a Qualified Medical Evaluator | Free Download

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

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.

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