Download Free QME Form 121 – Protection of Mental Health Record
The QME Form 121 is an important document used in California workers’ compensation cases to ensure the confidentiality of an injured worker’s mental health records. A Qualified Medical Evaluator (QME) must complete this form when handling cases involving mental health conditions to confirm they will protect sensitive medical information.
What is QME Form 121?
QME Form 121 is a declaration form that:
- Ensures an injured worker’s mental health records remain confidential during a worker’s compensation evaluation.
- Confirms the QME understand the responsibility in handling sensitive mental health information of the worker.
- Meets California Division of Worker’s Compensation (DWC) requirements for proper medical record management.
Who Needs to Use QME Form 121?
This Declaration Regarding Protection of Mental Health Record form must be completed by:
-
- QMEs who are assessing an injured worker’s mental health condition.
- Medical professionals who need to access the mental health records during a Worker’s Compensation evaluation.
Template Categories
California
General
How to use Regarding Protection of Mental Health Record Form
- Download the provided form by clicking the button and providing your email address.
- Receive the form directly in your inbox and download from there.
- Fill in the required details, including the QME’s name, case information, and declaration statement.
- Sign and submit the form before reviewing any mental health records.
The completed form should be submitted to the appropriate workers’ compensation claims administrator or as directed by the DWC Medical Unit.
Download the QME Form 121 Template for Free
Get your free QME Form 121 template to ensure proper handling of mental health records in workers’ compensation cases.
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...