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Free QME Form 120 Template – Download Now!

Access the QME Form 120 template for free. This form allows injured workers in California workers' compensation cases to choose a physician to receive their psychological injury evaluation report.

Free Download

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.

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.

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