Qualified Medical Evaluator Forms

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AME or QME declaration of service of medical – legal report	QME Form 122
Application for accreditation or re-accreditation as education provider - Instructions	QME Form 118
Application for appointment as qualified medical evaluator	QME Form 100
Declaration regarding protection of mental health record	QME Form 121
QME appointment notification form	QME Form 110
QME disclosure of specified financial interests	QME Form 124
QME notice of unavailability	QME Form 109
QME or AME conflict of interest disclosure form and objection or waiver - Instructions	QME Form 123
QME/AME report time frame extension request	QME Form 112
Qualified medical evaluator's findings summary form (unrepresented cases only)	QME Form 111
Reappointment application as qualified medical evaluator	QME Form 104
Registration for QME competency examination	QME Form 102
Voluntary directive for alternate service of medical-legal evaluation report on disputed injury to psyche	QME Form 120

Christina Elliott and Dana Livingstone-Lopez are co-editors and partners in Elliott-Lopez Publications, Inc. Each brings her own talents, skills and knowledge to the business with extensive experience with California Workers' Compensation and Occupational Medicine. Based in San Diego County, the partners are both dedicated to being of service to medical professionals in obtaining and maintaining Qualified Medical Evaluator certification in conjunction with Livingstone-Lopez Consulting (DWC Education Provider #470) of which Ms. Lopez is the principal.