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State of California DIVISION OF WORKERS COMPENSATION MEDICAL UNIT DECLARATION REGARDING PROTECTION OF MENTAL HEALTH RECORD (Health and Safety Code 123115(b) and 36.5, Title 8, California Code of Regulations)

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What is qme form 121 declaration?

QME Form 121 declaration is a form used to declare information related to a Qualified Medical Evaluator (QME) in workers' compensation cases.

Who is required to file qme form 121 declaration?

Qualified Medical Evaluators (QMEs) are required to file QME Form 121 declaration.

How to fill out qme form 121 declaration?

To fill out QME Form 121 declaration, you need to provide necessary information about the QME, such as their name, contact information, license number, and any changes to their practice.

What is the purpose of qme form 121 declaration?

The purpose of QME Form 121 declaration is to ensure that accurate and up-to-date information about the QME is available to the appropriate parties in workers' compensation cases.

What information must be reported on qme form 121 declaration?

QME Form 121 declaration requires reporting of the QME's name, contact information, license number, any previous names used, any changes to practice location or contact details, and any disciplinary actions taken against the QME.

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