Free QME Form 120 Template – Download Now!
The Voluntary Directive for Alternate Service of Medical-Legal Evaluation Report on Disputed Injury to Psyche (Form 120) is used in California workers’ compensation cases when an injured worker wants their psychological injury evaluation report sent to a designated physician instead of receiving it directly. This ensures the worker has a doctor present to review the report and explain its findings.
Why Use Form 120?
This form is helpful for injured workers, especially those without an attorney, who:
- Prefer to have a physician review the report with them before seeing it.
- Want clarifications on the report’s medical conclusions.
- Are involved in a workers’ compensation dispute regarding a psychological injury.
Who Can Use This Form?
- Injured workers with a disputed mental health injury in a workers’ compensation claim.
- Qualified Medical Evaluators (QMEs), who must send the report to the designated physician and claims administrator.
Template Categories
California
General
How to Use Form 120
- Download the free template from this page by providing your email address.
- Fill out the form, listing the physician who should receive the report.
- Sign and submit the form to ensure the QME sends the report to the selected doctor instead of the injured worker directly.
Download the Free Form 120 Template Now
Take control of your medical-legal report delivery in your workers’ compensation case. Download the free Form 120 template now to ensure your psychological injury evaluation report is reviewed properly.
Related Templates
QME Appointment Notification Form 110 – Free Template Download
QME Appointment Notification Form 110 – Free DownloadThe QME Appointment Notification Form 110 is an essential document used in California’s worker’s compensation cases to officially inform all parties involved- injured workers, employers, and legal representatives-...
Notice of Late QME Report (QME Form 116) – Free Template Download
Notice of Late QME Report (QME Form 116) – Free Template DownloadThe Notice of Late QME Report or QME form 116 is an important document used in California Worker’s Compensation cases to inform all parties involved that a Qualified Medical Evaluator (QME) has not...
Free QME Form 108 Template for QME Panel Selection
Free QME Form 108 Template for QME Panel SelectionThe QME Form 108, also known as the Qualified Medical Evaluator Panel Selection Instruction Form, is an essential document used in California workers' compensation cases. It provides crystal clear instructions to...
Doctor’s First Report Injury Form for Occupational Injuries: Download Free
Doctor’s First Report Injury Form for Occupational Injuries: Download FreeThe Doctor’s First Report of Injury Form or Report 5021, is an important document for recording workplace injuries and occupational illnesses. This form provides vital medical details that help...
Free DWC Application for Adjudication of Claim Template – Download Now!
Free DWC Application for Adjudication of Claim Template – Download Now!The DWC Application for Adjudication of Claim is a legal form used in workers' compensation cases to formally dispute a claim. If an injured worker and their employer or insurance company cannot...
Free DWC Form 113 Template – Denial of Time Extension Form
Free DWC Form 113 Template – Denial of Time Extension FormThe Denial of Time Extension (DWC Form 113) is an official form used in California workers' compensation cases to notify all parties involved in the case when a Qualified Medical Evaluator (QME) has requested...
Sample Disability Questionnaires: Essential for Disability Assessment
Sample Disability Questionnaires: For Disability AssessmentOur Disability Questionnaire templates are essential tools for employers, healthcare providers, and medical examiners to assess an individual's ability to work and determine eligibility for disability...
Free QME Form 102 Template – Register for the QME Competency Exam
Free QME Form 102 Template – Register for the QME ExamThe QME Form 102 is the official registration form for the Qualified Medical Evaluator (QME) competency exam in California. Physicians must complete this form to sign up for the exam, which is required to become a...
Free Referral for Specialist Medical Opinion Template
Free Referral for Specialist Medical Opinion Template – Download NowA Referral for Specialist Medical Opinion Regarding Work Capacity is used when an employer or doctor needs a specialist’s evaluation to determine whether an employee can safely perform their job...