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Range of motion testing as appropriate of neck, shoulders, elbows, forearm, wrist and fingers for pain, range limitation, crepitus at joint or tendon sheath, tendon triggering or locking. On range of motion testing of tendinitis/tenosynovitis, the focal discomfort is typically increased by passive stretching of the affected tendon, especially with composite range of motion testing. Associated symptoms descriptive of triggering, crepitus weakness and/or limited motion may be present.
Muscle strength testing may include such specific areas as the abductor pollicis brevis, resisted palmar abduction of the thumb for nerve entrapment syndromes. Serial grip strength measurements with a dynamometer may be useful in following clinical progress of tendinitis/tenosynovitis.
Provocative maneuvers for tendinitis, muscle strain, tendon subluxation, joint/ligament instability, nerve entrapment, and if warranted, thoracic outlet syndrome. Consider more specific tests such as: Tinel's - performed by percussing lightly along the projection of the given nerve, Phalen's - sustained wrist flexion for 60 seconds, and Finkelstein's - pain over the radial styloid is augmented by gentle passive ulnar deviation of the wrist with the thumb held adducted in the palm. It should be remembered that positive results from Finkelstein's test may also be obtained not only in de Quervain's tenosynovitis, but also in the presence of the following conditions: inflammation of the wrist extensor tendons (intersection syndrome), and entrapment of the superficial dorsal radial sensory nerve (Wartenberg's syndrome).
Neurologic testing including reflexes: biceps, triceps and brachioradialis; sharp/dull, light touch, two-point, or vibratory sensory testing; strength testing by resisted movement and grip strength dynamometer, if available.
Circulatory evaluation of radial and ulnar arterial sufficiency.
1.2.3 Diagnostic imaging
1.2.3.1 Plain films of the forearm, wrist or hand may be done after taking a medical history, performing a physical examination, and determining that this study is medically relevant. [4]
1.2.3.2 CT, MRI, isotope, or similar scans of the wrist are not warranted unless there is a specific, suspected, clinical entity appropriate for the study. The examiner requesting this study should plainly state the reason for requesting the study and the treatment plan related to the results. [4]
1.2.4 Laboratory Testing
a. Tendinitis/tenosynovitis or wrist pain: Certain blood tests can be useful in establishing the diagnosis of an underlying metabolic or rheumatologic disease if such a condition is suspected on the basis of the history and physical examination during the evaluation of probable tendinitis/tenosynovitis or wrist pain. [4]
b. Nerve entrapment syndromes: During the evaluation of probable, entrapment syndromes, laboratory tests should be done if a contributing systemic diagnosis such as joint disease, diabetes mellitus, or thyroid disease is suspected. [4]
1.2.5 Diagnostic Injections
Diagnostic injection of local anesthetic by the experienced, may be useful for diagnosis in the case of atypical presentations such as referred pain or the presence of multiple disorder. [3]
1.2.6 Electromyography and Nerve Conduction Tests.
Nerve entrapment syndromes: The initial history and physical exam are the most important assessment tools and the working diagnosis may be made without confirmation by nerve conduction studies. [4]
1.3 Inappropriate initial assessment methods
1.3.1 Thermography [1]
1.3.2 Vibrometry [1]
1.3.3 Portable neurometer [1]
1.3.4 Electrodiagnostic testing to establish the diagnosis of de Quervain's tenosynovitis [1]
2.0 Initial Treatment
2.1 Purpose
The purpose of initial treatment is to promote healing, optimize function and allow continued productive employment with appropriate modifications, as indicated, to avoid adverse effects. The initial treatment of nerve entrapment syndromes, tendinitis, tenosynovitis, and wrist pain is nonsurgical. Application of the conservative therapy described below will result in significant improvement in a majority of cases. Effective workplace intervention may be crucial. The period of initial (conservative) treatment should be 4 weeks with re-evaluation at least every two weeks to ascertain improvement.
2.2 Appropriate initial treatment methods
2.2.1 Education

a. All injured workers with these conditions should receive instruction concerning the anatomy and nature of their condition, risk factors, preventive measures, appropriate exercises and goals of the initial treatment methods including time frame for expected improvement. [4]
The responsibilities of the injured worker in implementing the treatment plan should be emphasized. Education should be provided by the treating physician and may be supplemented by a physical or occupational therapist in the context of referral for the instruction on gentle flexibility and range of motion exercises, joint protection, work simulation and conditioning. Educational literature, if provided, should be reviewed with the injured worker. Home hobby, craft, sport and avocational activities should be curtailed, as appropriate, if they are considered to be potentially aggravating or causative factors.
2.2.2 Activity and Environmental Modifications
a. If occupational factors cause or aggravate the condition, appropriate work restrictions and/or ergonomic workplace changes may be advised by the provider. These should protect the involved tissues while allowing the injured worker to perform some of the specific elements of the job. [4]
b. Modified work is strongly encouraged since initial treatment need not require time lost from work. [4]
Prescribed modified work guidelines should be as specific as possible, avoiding generic terms such as "light duty." Examples of restrictions are a reduction in daily hours, complete restriction from aggravating or high risk tasks, or specific job rotation to promote varied hand position and activities. Other examples of such modifications include work station adjustment, tool redesign, protective equipment and other engineering controls. It may be necessary to contact the company directly to discuss alternative productive work within the scope of the prescribed restrictions.
2.2.3 Immobilization/Stabilization
a. Nerve entrapment syndromes: Immobilization/stabilization of the wrist in a neutral position may be used and is most effective when worn in the night. [4]
The splint should prevent wrist flexion and extension without constriction. If not properly fitted, it can lead to further nerve entrapment, muscle atrophy, vascular compression, discomfort and chafing.
If a pre-formed splint does not fit properly a custom-made splint may be fabricated. [4]
b. Severe de Quervain's tenosynovitis: Immobilization of the wrist and thumb interphalangeal joint with a spica thumb splint or other similar device can be considered for up to 3 to 4 weeks. [4]
Splinting may not be necessary in milder cases and the functional restriction on thumb and hand use imposed by spica splinting is considerable.
c. Tendinitis/tenosynovitis: Immobilization with appropriate splints should also be considered in case of moderate and severe tendinitis/tenosynovitis or for short-term(up to 4 weeks) care of wrist pain. [4]
d. Splints must fit properly and should be prescribed by the provider. [4]
The injured worker should be instructed in proper use of the splint, including the practice of range of motion exercises throughout the day. Careful monitoring of clinical progress is necessary during splinting to avoid the complications of muscle atrophy and joint stiffening.
2.2.4 Physical Treatments
a. Appropriate manual/manipulative therapies, including joint and soft tissue mobilization may by used up to a maximum of 12 treatment visits. Referral to an appropriate provider should be considered." [3]
b. Various manual and/or passive modalities should not be utilized as the sole treatment. A graduated exercise program to promote strength, flexibility, and normal function should also be utilized. [3]
c. Acupuncture may be prescribed up to a maximum of 12 treatments in 4 weeks. [3]
2.2.5 Passive Modalities
a. Active physical treatments can be supplemented by selected passive modalities (heat, cold, ultrasound, electrical stimulation, iontophoresis, phonophoresis, aquatic therapy) at the discretion of the provider for the first 4 weeks of treatment. [4]

b. Ice treatment periods should not exceed twenty minutes. Application of appropriate modalities at home may also be useful during and following the acute inflammatory phase. [3]
2.2.6 Medications
2.2.6.1 A physician may prescribe appropriate analgesic and/or anti-inflammatory medications. [4]
2.2.6.2 Local injection of steroid medication (with or without accompanying local anesthetic can be used as an initial treatment modality for cases of (1) moderate to severe inflammation or (2) stenosing tenosynovitis which affects function, after consideration of the risks of this procedure. [4]
2.2.7 Surgical Referral for Nerve Entrapment Syndromes
Surgical consultation should be made in the initial treatment phase if there is: 1) thenar muscle weakness or atrophy; 2) unremitting sensory loss or paresthesia 3) significant hand dysfunction; 4) evidence of a space occupying lesion or history of acute or traumatic onset. In these instances, an EMG/nerve conduction study may be performed to confirm the diagnosis. [4]
2.3 Inappropriate Initial Treatments
2.3.1 Surgical Treatments
a. Surgical treatment of de Quervain's tenosynovitis or hand and wrist tendinitis/tenosynovitis without a trial of therapy, including a work evaluation, is generally not indicated. [1]
2.3.2 Medication
a. Pyridoxine / Vitamin B6
b. Oral corticosteroids
2.3.3 Tendinitis/tenosynovitis or wrist pain: Prolonged application of passive modalities (beyond 4 weeks) [1]
2.4 Case Management
During the first month of evaluation and treatment, the case management decisions must be made by the treating physician(s), based on the injured worker's clinical progress. Re-evaluation of the diagnosis, treatment effectiveness and work status should be performed by the physician at least every 2 weeks. Referral to an appropriate provider during the initial phase of treatment may be indicated for patient education, pain reduction and the implementation of a graduated program of flexibility and conditioning exercises. Referral should be considered for all patients with moderate to severe symptoms, those assigned total temporary disability and those undergoing surgical treatment.
The goal is to promote healing and maximize function for a gradual return to occupational and non-occupational activities.
Referral to a surgeon competent in the treatment of hand and wrist disorders is appropriate after failure of conservative treatment.
3.0 Secondary Assessment (Reassessment at 4 weeks)
3.1 Purpose
The purpose of the secondary assessment is to identify the reason(s) for delayed recovery from wrist/hand symptoms and/or functional impairment after initial evaluation and treatment. This requires review of both the working diagnosis and differential diagnosis, as well as the contributing factors and the treatment approach.
3.2. Appropriate Secondary Assessment Methods
3.2.1. History
The interval history should document the treatment measures prescribed and implemented, and the evolution of symptoms during this treatment. The previously recommended modifications of occupational and nonoccupational activities should also be reviewed. Current work status should be noted. If there has been no significant improvement, or worsening of symptoms, the history should be carefully reviewed to address other co-existing or contributing musculoskeletal pathologies and systemic illnesses as per the Initial Assessment section.
3.2.2 Physical Examination

A reexamination should assess any changes in the upper extremity, especially tenderness, atrophy, range of motion, serial grip strength, and response to provocative maneuvers.
Attention should be paid to any changes in the provocative and sensibility tests. If symptoms have worsened or remain unimproved, the physical exam should include an evaluation for undiagnosed proximal upper extremity and neck pathology.
3.2.3 Diagnostic Imaging
3.2.3.1 If not previously performed or unavailable, plain films of the forearm, wrist or hand may be considered after the medical history and physical examination indicate that this study is medically relevant. [4]
3.2.3.2 CT, MRI, isotope, or similar scans of the wrist are not warranted unless there is a specific, suspected, clinical entity which may be diagnosed by the study. The examiner requesting this study should justify the rationale for requesting the study and for supporting the treatment plan. [4]
3.2.4 Laboratory Studies
Certain laboratory studies may be useful in establishing the diagnosis of an underlying metabolic or rheumatologic disease if such a condition is suspected. [4]
3.2.5 Diagnostic Injections
Diagnostic injection of local anesthetic may be useful for diagnosis in the case of atypical presentations (e.g. referred pain, presence of multiple disorders). [3]
3.2.6 Electromyography and Nerve Conduction Tests
3.2.6.1 Wrist pain and tendinitis/tenosynovitis
Electrodiagnostic studies are appropriate if neuropathy is suspected from the history and physical examination. [4]
3.2.6.2 Nerve Entrapment Syndromes: [4]
Nerve conduction studies may be useful in the re-evaluation phase and should be reserved for:
1) cases of persistent or worsening symptoms and clinical signs despite a trial of conservative treatment;
2) cases where the diagnosis remains in question and the history and physical exam are suggestive of another type or location of nerve pathology.
Electrophysiologic studies can be falsely negative in 10-20% of individuals with clinical CTS and false-positives in asymptomatic people do occur rarely. Therefore the results must be considered in the context of the history, physical exam and presence of occupational risk factors.
A complete evaluation should include distal median and ulnar nerve sensory and motor nerve conduction studies under controlled limb temperature conditions. The laboratory standards for an abnormal test should be consistent with published values and stated in the report. Nerve conduction studies are also useful to determine the site of nerve impingement if a more proximal location is suspected, and can be helpful in the detection of a generalized polyneuropathy.
3.2.7 Ergonomic Evaluation
If continued occupational exposure to exacerbating factors is contributing to delayed recovery a worksite evaluation by a specialist trained in ergonomics may be necessary. [4]
3.2.8 Psychological evaluation
A psychological evaluation with justification may be appropriate in cases where little clinical improvement is noted. [3]
3.3 Inappropriate secondary assessment methods
3.3.1 Vibrometry [1]
3.3.2 Portable neurometer [1]
4.0 Secondary Treatment
4.1 Purpose
4.1.1 Nerve entrapment syndromes: The goal of secondary treatment is the symptom-free return to full employment (in a graded manner) with the provision of appropriate immediate and long-term work and activity modifications to prevent recurrence. Continuance of conservative treatment is warranted if symptoms are improving. If there has been no improvement, or clinical progression despite the injured worker's compliance with the initial treatment protocol (including adherence to work restrictions) further treatment strategies are recommended. These should also be considered in the injured worker who has initial improvement but plateaus with persistent symptoms during the continuation of conservative care. If there has been documented consistent improvement of symptoms and physical findings with adherence to the Initial Treatment Protocol outlined above, continued conservative treatment is warranted for up to 2-4 more months (for a total of approximately 6 months), with re-evaluation every 2-4 weeks.
If there has been documented, consistent improvement of symptoms and physical findings with adherence to the Initial Treatment Protocol outlined above, continued conservative treatment is warranted.
4.1.2 Hand and wrist tendinitis/tenosynovitis: The purpose of secondary treatment of hand and wrist tendinitis/tenosynovitis is to optimize recovery from persistent symptoms. Most cases will respond to continued nonsurgical therapy. Secondary treatment for wrist pain will be diagnosis specific and designed to optimize recovery from persistent wrist pain causing conditions.
4.2 Appropriate secondary treatment methods
4.2.1 Education
As part of the continuing medical and physical treatment programs, all patients should receive instruction reviewing their clinical progress, time frame for expected improvements, risk factor, preventive measures, appropriate exercises and treatment options. [4]
Such instruction should be provided by the treating physician and may be supplemented by a physical or occupational therapist as part of an appropriate referral for flexibility and strengthening training.
4.2.2 Activity and environmental modifications
4.2.2.1 Restriction of occupational and nonoccupational activities which stress the affected area (via direct pressure, forceful or repetitive motion or static tension) should be continued or gradually relaxed based upon the clinical status. [4]
Prescribed modified work guidelines should be as specific as possible, avoiding generic terms such as "light duty." Further direct communication with the employer can facilitate the permanent implementation of job task, tool, and workstation modifications to speed recovery and prevent recurrence.
4.2.3 Immobilization
a. de Quervain's: Immobilization/stabilization for de Quervain's tenosynovitis of the wrist and thumb joint with a spica thumb splint or other device should usually not be continued for more than 4 weeks. [4]
b. Hand and Wrist Tendinitis: Immobilization/stabilization with appropriate splints should be reduced as soon as the symptoms improve (e.g. use limited to performing exacerbating tasks), and discontinued when the symptoms are mild. [4]
Continuous splinting should not exceed 4 weeks duration; intermittent or nocturnal splint use may be applied for longer periods. [4]

Institution of splinting can be considered as a secondary treatment for persistent or worsening cases. [4]
c. Nerve entrapment syndromes: If splinting has been on a continuous basis, it may be reduced to nighttime use only or PRN use for aggravating activities. [4]
4.2.4 Physical Treatments
a. Graduated exercises as described in initial treatment may be continued during the rehabilitative process. [4]
b. Manipulation/mobilization for joint dysfunction (not for nerve entrapment): After 6 treatment visits, an evaluation should be made to determine subjective and objective improvement. If there is no documented subjective and objective improvement, this modality should be discontinued. [3]
c. Referral to an appropriate provider for training in flexibility and strengthening exercises can be considered for tendinitis/tenosynovitis. The duration of secondary physical treatment referral should not exceed 4 to 6 weeks. [4]

d. Acupuncture [3]
e. Biofeedback [3]
4.2.5 Passive Modalities
Use of thermal modalities in conjunction with physical treatment may be useful in the treatment of tendinitis, tenosynovitis, de Quervain's, and wrist pain.
4.2.6 Medications
a. Tendinitis/tenosynovitis/wrist pain: Oral nonsteroidal antiinflammatory medications (NSAIDs) may be continued judiciously after consideration of their cumulative adverse effects risk. Opioids should be reserved for pain refractory to other medications. [4]
b. Nerve entrapment syndromes: If anti-inflammatory agents have been used continuously in the initial 6-8 weeks of treatment, they should be discontinued as the risk of side-effects outweighs potential benefits. [4]

They may be re-instituted for brief trials in the event of symptom flare.
Acetaminophen may be used periodically. [4]
4.2.7 Injection
4.2.7.1 Tendinitis/Tenosynovitis
a. If not used during the first month, local injection of steroid medication (with or without accompanying local anesthetic medication)can be used for cases of persistent symptoms after consideration of the risks of this procedure. [4]
b. Repeat corticosteroid injections can be given at intervals, to a maximum of 3 injections during the course of the second and third months. [4]
c. The suspected presence of focal infection (e.g. tuberculous tendinitis) is a contraindication to steroid injection. Extra caution is warranted in the injection of steroids around the extensor pollicis longus tendon at or distal to Lister's tubercle given the elevated risk of tendon rupture. [4]
d. Steroid injection therapy must be accompanied by the activity modifications discussed above.
4.2.7.2 Nerve Entrapment
Nerve Entrapment corticosteroid injection (with or without local anaesthetic) can be considered if significant symptoms (especially paresthesias) persist. [4]
Injections are only occasionally curative, usually in the injured worker who has been symptomatic for less than three months. A significant percentage of people have attenuation of their symptoms with injection, a good prognostic sign if surgery is eventually necessary. Symptoms frequently return within weeks to months. If there is improvement in symptoms, the injection serves as a diagnostic aid. If relief is prolonged (weeks to months), repeat injections can be given, to a maximum of three, at intervals not less than 6-8 weeks apart.
Contraindications - drug allergy, bleeding disorder, space-occupying lesion.
Potential complications - local hematoma, infection, tendon rupture, reflex sympathetic dystrophy, and inadvertent injection of the median nerve with worsening symptoms. Transient median nerve symptoms occur frequently.
4.2.8 Surgical Treatments
4.2.8.1 Tendinitis/Tenosynovitis
a. Surgical intervention can be considered for cases showing little or no improvement after failure of conservative therapy. [4]
b. Many cases of refractory tendinitis/tenosynovitis are due to the presence of conditions which are not amenable to nonsurgical treatment (e.g. anomalous tendon slips, strictures, large calcifications, tendon subluxation. [4]
4.2.8.2 Nerve entrapment syndromes: Surgical consultation in the re-assessment phase is indicated if: [4]
a. the diagnosis of Nerve Entrapment Syndromes has been reasonably established and other pathologies excluded; and
b. atrophy or weakness is present; or
c. there is unremitting sensory loss or paresthesias or markedly abnormal nerve conduction studies; or
d. the injured worker has failed a 3-6 month course of adequate conservative therapy; or
e. the symptoms and physical signs continue to progress during conservative therapy.
Surgery should be performed only by a Hand, Orthopedic, Plastic, or Neuro Surgeon with extensive experience in the selection of candidates for surgical intervention and in the procedure itself. Surgical aftercare should be managed by the surgeon.
4.2.8.3 Surgical procedures are indicated for an appropriately diagnosed, surgically correctable lesions.
4.3 Inappropriate Secondary Treatment Methods
4.3.1 Medications
a. Use of oral corticosteroids is rarely indicated. [1]

b. Pyridoxine / Vitamin B6 [1]
c. Muscle relaxants [1]
4.4 Case management
If the injured worker has not resumed near normal work duties after 8 weeks of full conservative therapy including adherence to a graded exercise program, a referral to a physician trained and experienced in the evaluation and treatment of occupational disorders or an orthopedic surgeon is recommended. Consultation should include a complete evaluation and recommendations for treatment and return to appropriate work. If psychosocial issues are judged to contribute to delayed recovery or heightened disability, it may be appropriate to have a psychiatric evaluation. If the condition becomes chronic or disabling despite full conservative treatment including appropriate medical, rehabilitative, and ergonomic interventions (and surgery if indicated), the injured worker should be evaluated for permanent disability.
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Appendix 6.0 Extensor and Flexor Tendon Compartments
Extensor compartments
1. Abductor pollicis longus and extensor pollicis brevis (de Quervain's tenosynovitis)
2. Extensor carpi radialis longus & brevis (Intersection syndrome)
3. Extensor pollicis longus
4. Extensor indicis proprius, extensor digitorum communis
5. Extensor digiti minimi
6. Extensor carpi ulnaris
Flexor compartments
1. Flexor carpi radialis
2. Flexor carpi ulnaris
3. Flexor digitorum superficialis &profundus
4. Flexor pollicis longus
Appendix 6.0: Wrist Pain - Differential Diagnosis (adapted from Chidgey article)
Bone/Joint
Fracture (occult/nonunion/malunion)
Avascular necrosis: scaphoid, lunate
Joint subluxation: distal radioulnar joint
Carpal instabilities (static/dynamic): scapho-lunate dissociation, etc/
Arthritis/Arthrosis
Post-traumatic, osteoarthritis, rheumatoid, gout, pseudogout, infection, etc.
Osteomyelitis
Bone cyst
Ganglion cyst (intraosseous/extraosseous)
Tumor (benign/malignant): enchondroma, osteoid osteoma, etc.
Other: carpal boss, os styloideum
Ligament
Tear/avulsion ((no/) static/dynamic instability): triangular fibrocartilage, intercarpal ligament tears/ruptures etc.
Sprain
Tendon
Subluxation: extensor carpi ulnaris
Tendinitis: six extensor and three flexor wrist compartments (noncalcific/calcific)
Muscle
Muscle strain
Chronic compartment syndrome
Nerve
Neuroma
Neuropathy: median, ulnar, posterior interosseous, cutaneous sensory nerves, proximal source
Compression/entrapment, toxic/metabolic, inflammatory, etc.
Circulatory
Ischemia
Thrombosis
Aneurysm
Other
Appendix 7.0 Description of IMC Appropriateness Levels

Level 4 Level 3 Level 2 Level 1


Good Research Yes No No No
Based Evidence
Clinical Evidence Yes Yes Some No
Consensus Of The Yes Yes Partial No
Health Care Community
Clinical Utility Approp- Accepta- Appropriate
riate ble
Of Appropriateness and or appr- in uncommon Inappropriate
opria-
te
Level For Common recomm- in most individual cases.
ended
Knee cases Document the
case-specific
Problems clinical factors circumstances
or which make this
procedure

reasonable and
necessary for this
injured worker.






Note: Authority cited: Section 139(e)(8), Labor Code. Reference: Section 139(e)(8), Labor Code.






s 100. The Application for Appointment as Qualified Medical Evaluator Form.


QME FORM 100 (Rev. 1/2006)


QME FORM 100 (Rev. 1/2006)


QME FORM 100 (Rev. 1/2006)


QME FORM 100 (Rev. 1/2006)
For Use on the QME Reappointment Application Form

IMPORTANT: PLEASE USE THREE LETTER SPECIALTY CODE WHEN COMPLETING BLOCK 8 OF
APPLICATION FORM



Attachment to Form 100
(Rev. 1/2006)






s 101. The Alien Application Form.


Form 101 Rev. 3/01/00


Form 101 Rev. 3/01/00


Form 101 Rev. 3/01/00


(IMC 101).
IMC 101
(IMC 101)
(IMC 101
IMC 101






s 102. The Application for QME Competency Examination Form.


STATE OF CALIFORNIA ARNOLD SCHWARZENEGGER, GOVERNOR
DEPARTMENT OF INDUSTRIAL RELATIONS
DIVISION OF WORKERS'COMP-MEDICAL UNIT
1515 Clay Street, 17th Floor ADDRESS REPLY TO:
Oakland, CA 94612 P.O. Box 420603
Tel: (510) 286-3700 or (800)794-6900San Francisco, CA 94142-0603
REGISTRATION

FOR

QME COMPETENCY EXAMINATION

(DATE)

PLEASE COMPLETE THIS REGISTRATION FORM AND RETURN POSTMARKED NO LATER THAN (Date). THE DIVISION OF WORKERS' COMPENSATION (DWC) IS NOT RESPONSIBLE FOR LATE OR LOST APPLICATIONS. PLEASE SEND YOUR REGISTRATION AND APPLICATION FORMS TO:
DIVISION OF WORKERS' COMPENSATION - ATTN: EXAM UNIT

MAILING ADDRESS: STREET ADDRESS FOR EXPRESS DELIVERY:
P.O. BOX 42060 31515 CLAY STREET 17th FLR.
SAN FRANCISCO, CA 94142-0603 OAKLAND, CA 94612
NAME: __________, __________, __________, __________
LAST FIRST M.I. JR/SR.
ADDRESS: (street address) __________ __________
(city) __________, CA (ZIP) __________(+4) __________
PHONE NUMBER: ( ____ ) _____- _______
FAX NUMBER: ( ____ ) _____- _______
PHYSICIAN'S LICENSE NUMBER: __________-______________
Prefix Number
EXAM DATE & TIME: (Date) Registration begins at 9:30 a.m. Examination begins at 10:00 a.m.MP21PREFERRED EXAM LOCATION:(TEST SITE WILL BE INDICATED ON YOUR CONFIRMATION LETTER FROM CPS.)
[ ] Northern California [ ] Southern California
DO YOU HAVE ANY NEED FOR ACCOMMODATIONS DUE TO A DISABILITY OR RELIGIOUS CONFLICT?
[ ] No [ ] Yes (Please see the Special Administration Procedures at the back of this page.)
AFFIRMATIONS and VERIFICATION I have used all reasonable diligence in preparing and completing this application. I have reviewed this completed application and to the best of my knowledge the information contained herein and in the attached supporting documentation is true, correct and complete. I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. I understand that I must keep my license to practice active and that it currently is active. I certify that I am not currently on probation with my licensing board nor on any court-ordered probation. I certify I will notify the DWC of any of the following events: a) change in my license status; b) any past or future conviction related to the conduct of my practice or for any crime of moral turpitude; and c) upon being placed on probation by my licensing board or by any court-ordered probation. I certify that all the information and supporting documentation which I have previously submitted to the DWC with earlier QME application(s) is bona fide, true and correct. Executed on: __________ at ____________________ ________________________
mm/dd/yy County & State Applicant's Signature
(OVER)
Registering for Special Administration Procedures

Examinee with a Disabling Condition or Religious Conflict
Special administration arrangements can be provided for examinees who, due to a disability or religious conflict, would not be able to take the test under standard conditions. Requests for special arrangements must be made by the REGULAR REGISTRATION DEADLINE. It may not be possible to honor requests for special testing arrangements received after the regular registration deadline.
Individuals whose religious convictions prohibit them from taking tests on Saturdays or religious holidays may request a special test administration.
All of the following must be submitted if special arrangements are needed due to a disability:
a letter from you describing the condition and the specific special arrangements requested, and
a completed registration form.
YOUR PROFESSIONAL LICENSE NUMBER AND TELEPHONE NUMBER MUST APPEAR ON ALL CORRESPONDENCE.
If you need special facilities (e.g. wheelchair accessible building or restrooms), please notify by letter to Cooperative Personnel Services (CPS) at 241 Lathrop Way, Sacramento, CA 95815. In this case, it is not necessary to submit any medical documentation.
Special arrangements for the following conditions can be accommodated at ALL test sites:
special seating (e.g., due to pregnancy)
wheelchair accessible facilities
use of magnifying devices or large-print tests (e.g., for those with visual impairments).
Arrangements that require SUBSTANTIAL CHANGES IN TESTING CONDITIONS may be accommodated only at selected test sites. If it is necessary to relocate you to accommodate any other type of request, you will be contacted directly to discuss the arrangement.
QME Form 102
Rev. 1/2006






s 103. The QME Fee Assessment Form.


STATE OF CALIFORNIA GRAY DAVIS, GOVERNOR
DEPARTMENT OF INDUSTRIAL RELATIONS INDUSTRIAL MEDICAL COUNCIL
395 Oyster Point Blvd., Ste. 102
South San Francisco, CA 94080
ADDRESS REPLY TO:
P.O. Box 8888
San Francisco, CA 94128-8888
Tel: (650) 737-2700 (1-800) 794-6900 Fax: (650) 737-2711

Fee Period: - License Number:
Dear Dr.:
Pursuant to Labor Code s 139.2(n) and 8 CCR, s 18, the Industrial Medical Council requires all physicians appointed or reappointed as Qualified Medical Evaluators (QMEs) to pay an annual fee. The QME fee is non-refundable.
$250 FEE
QMEs who have conducted 25 or more comprehensive medical - legal evaluations in the twelve months prior to assessment of the fee. All evaluations performed as a Qualified Medical Evaluator, Agreed Medical Evaluator, and Independent Medical Evaluator must be counted for the purpose of fee assessment (8 CCR ss 16, 17).
$125 FEE
QMEs who have conducted 11-24 comprehensive medical legal evaluations in the twelve months prior to assessment of the fee. All evaluations performed as a Qualified Medical Evaluator, Agreed Medical Evaluator, and Independent Medical Evaluator must be counted for the purpose of fee assessment (8 CCR ss 16, 17).
$110 FEE

QMEs who have conducted 0-10 comprehensive medical legal evaluations in the twelve months prior to assessment of the fee. All evaluations performed as a Qualified Medical Evaluator, Agreed Medical Evaluator, and Independent Medical Evaluator must be counted for the purpose of fee assessment (8 CCR ss 16, 17).
ADDITIONAL LOCATIONS
QMEs who perform evaluations at more than one medical office location are required to pay an additional $100 per location (8 CCR s 17).
Misrepresentation of the number of evaluations performed or the number of additional locations shall constitute grounds for disciplinary proceedings (8 CCR s 60).
Department of Industrial Relations Industrial Medical Council Location Fee
Calculation Worksheet

License Number:
Street, City, State, Zip Code, Phone No.

[ ]
[ ]
[ ]
Enter total Number of ALL location boxes checked - -> __________
________________________________________________________________
THIS SECTION MUST BE COMPLETED BY THE PHYSICAN.
____ $250 Primary fee for those physicans who have done 25 or more medical/legal evaluations.
____ $125 Primary fee for those physicans who have done 11-24 medical/legal evaluations.
____ $110 Primary fee for those physicans who have done 0-10 medical/legal evaluations.

Based on the amount of primary fee I have paid. I hereby declare under penalty of perjury under laws of the State of California that the foregoing is true and correct.
Physican's Signature___________________________ Date ___________
________________________________________________________________
IMC Form 103 Rev. 5/05/00







s 104. The Reappointment Application as Qualified Medical Evaluator Form.


REAPPOINTMENT APPLICATION AS QUALIFIED MEDICAL EVALUATOR

For the Department of Industrial Relations

Industrial Medical Council

P.O. Box 8888

San Francisico, CA 94128-8888

________________________________________________________________

BLOCK 1 (FOR ALL APPLICANTS) PLEASE TYPE OR PRINT LEGIBLY
Please list your primary location. DO NOT USE P.O. BOX. Additional locations
may be added when your fee assessment is paid.
LAST NAME FIRST NAME MI JR/SR
-------------------------------------------------------------------------------
BUSINESS ADDRESS FOR QME CITY ZIP + 4
EVALUAITONS
-------------------------------------------------------------------------------

MAILING ADDRESS FOR CITY ZIP + 4
CORRESPONDENCE
-------------------------------------------------------------------------------
CAL. PROFESSIONAL EXPIRATION
(AREA CODE) PHONE NO. LICENSE NUMBER (MM/YY)


________________________________________________________________
BLOCK 2 (FOR MDs AND DOs ONLY)
NOTE: APPLICANT MUST MEET ONE OF THE FOLLOWING REQUIREMENTS

Yes No
1) I am board certified in the specialty for which I am applying to ( ) ( )
become a QME by a board recognized by the Council and the Medical
Board of California or the Osteopathic Medical Board of
California. Date board certification expires, if
applicable___________________, (If you became board certified
after your last QME application, you must attach a copy of the
certificate of board certification).
2) I have completed the minimum requirements as definied by a ( ) ( )
specialty board recongnized by the Council for postgraduate

training in the specialty at an institution recognized by the
ACGME or the American Osteopathic Assocation on
_____________________.
(Date Completed)
3) I was an active qualified medical evaluator on June 30, 2000. ( ) ( )
4) I have qualifications that the Council and the Medical Board of ( ) ( )
California or the Osteopathic Medical Board of California both
deem to be equivalent to board certification in a specialty.
(Please submit documenation).


PROCEDD TO BLOCK 3

________________________________________________________________
BLOCK 3 (FOR ALL APPLICANTS) NOTE: APPLICANT MUST MEET ONE OFTHE FOLLOWING REQUIREMENTS

1) I devote at least one-third of my total practice time to ( ) ( )
providing direct medical treatment ('Direct Medical Treatment' is
the special phase of the health care provider-patient
relationship which (a) attempts to clinically diagnose and alter

or modify the expression of a non-industrial illness, injury or
pathological condition; or (b) attempts to cure or relieve the
effects of an industrial injury.)
2) I have served as an Agreed Medical Evaluator (AME) on eight (8) ( ) ( )
or more occasions in the 12 months prior to submitting this
application. (Submit documentation of 8 AME's, i.e. AME cover
letters, first page of report or a sworn statement made under
peralty of perjury.)
3) I am currently a salaried faculty member at an accredited ( ) ( )
university or college. I have a current license to practice as a
physican and have been engaged in teaching, lecturing, published
writing or medical research at that university or college in my
area of specialty for not less than one-third of my professional
time. My practice in the three consecutive years immediatley
preceding the time of application was not devoted solely to the
forensic evaluation of disability. (Please submit evidence of
your faculty appointment.)
4) I am retired from active practice. I have a minimlum of 25 ( ) ( )
years' experience in practice as a physician and currently I
practice fewer than 10 hours per week on direct medical treatment
as a physician. My practice in the three consecutive years

immediately preceding the time of reappointment was not devoted
solely to the forensic evaluation of disability.
5) I am retired from active practice due to a documented medical or ( ) ( )
physican disability as defined pursuant to Gov't Code s 12926 and
currently practicing in my specialty fewer then 10 hours per
week. I have 10 years' experience in workers' compensation
medical issues as a physican. My pracitce in the three
consecutive years immediately preceding the time of application
was not devoted solely to the forensic evaluation of disability.
(Please submit medical documentation of you disability.)


PROCEED TO BLOCK 4

________________________________________________________________
BLOCK 4 (FOR ALL APPLICANTS)
PLEASE INDICATE SPECICALTY(IES) FOR WHICH YOU ARE APPLYING TO DO OME EXAMS (USE ENCLOSED SPECIALTY CODE LIST)
Professional practice specialty code: (______) (continued)