QME Form 121 - State of California - dir ca 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling in the name of the injured employee in the designated area. This is crucial for identifying the individual related to the mental health record.
3. Next, enter your name and professional license details, including your type of license and license number, ensuring accuracy for legal compliance.
4. Provide the employee's information, including their address and phone number, along with their Workers' Compensation claim number and claims administrator's contact details.
5. In section three, describe why access to the mental health record could pose a risk to the employee’s well-being. Be specific about potential medical consequences.
6. Indicate the date you were asked to serve a copy of this medical record on the employee and confirm that you advised them about how they can obtain it through a licensed physician.
7. Complete sections regarding any designated physician for alternate service and document your response to the employee’s request for a copy of their record.
8. Finally, sign and date the declaration at the bottom of the form, ensuring all information is accurate before submission.

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