California Code of Regulations
Title 8 - Industrial Relations
Division 1 - Department of Industrial Relations
Chapter 1 - Division of Workers' Compensation - Qualified Medical Evaluator Regulations
Article 3 - Assignment of Qualified Medical Evaluators, Evaluation Procedure
Section 29 - Specified Financial Interests that May Affect Assignment to QME Panels

(a) Every physician seeking appointment or reappointment as a Qualified Medical Evaluator shall disclose specified financial interests, as defined in section of Title 81 (dd) and 29(b) of Title 8 of the California Code of Regulations.

(b) "Specified Financial Interests" means being a general partner or limited partner in, or having an interest of five (5) percent or more in, or receiving or being legally entitled to receive a share of five (5) percent or more of the profits from, any medical practice, group practice, medical group, professional corporation, limited liability corporation, clinic or other entity that provides treatment or medical evaluation, goods or services for use in the California workers' compensation system.

(c) "SFI Form 124", as used in sections 1 though 159 of Title 8 of the California Code of Regulations, means the QME SFI Form 124 that is completed and filed as an attachment to QME Form 100, 103 or 104 by the physician or QME with the Medical Director of the Division of Workers' Compensation.

(d) Specified financial interests shall be disclosed on QME SFI Form 124, respectively, when applying for appointment on QME Form 100, at the time of paying the annual fee on QME Form 103 or when applying for reappointment on QME Form 104.

(e) The completed QME SFI Form 124 shall be filed along with the QME Form 100, 103 or 104, respectively, when the form is filed with the Medical Director of the Division of Workers' Compensation.

(f) Failure of a Qualified Medical Evaluator to complete and file a QME SFI Form 124 with the Medical Director when required by this section shall be grounds for disciplinary action pursuant to section of Title 860 of Title 8 of the California Code of Regulations.

(g) The Administrative Director shall use the information provided by physicians pursuant to this section to avoid assigning QMEs who share specified financial interests to the same QME panel. If two or more QMEs assigned to a panel share specified financial interests as defined in this section, any party may request a replacement QME. If three QMEs share specified financial interests as defined in this section, two of the QMEs shall be replaced. If two QMEs share specified financial interests as defined in this section, one of the QMEs shall be replaced. The QMEs that must be replaced shall be randomly selected by the Medical Director.

NOTE: Forms referred to above are 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.