Download Free QME Form 121 – Protection of Mental Health Record | Free Download

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 sthe responsibility in handling sensitive mental helath iformation of the worker.

Meets California Division of Worker’s Compensation (DWC) requirements for proper medical recxord 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 ghealth condition.

Medical professionals who need to access the mental health records during a Worker’s Compensation evaluation.

How to use QME Form 121 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.

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