PDF
Word
QME Form 123 Qme or Ame Conflict of Interest Disclosure Form and Objection or Waiver - California
What Is QME Form 123?
This is a legal form that was released by the California Department of Industrial Relations - Division of Workers' Compensation - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.
FAQ
Q: What is QME Form 123?
A: QME Form 123 is a Conflict of Interest Disclosure Form and Objection or Waiver form in California.
Q: What does QME stand for?
A: QME stands for Qualified Medical Evaluator.
Q: What is the purpose of QME Form 123?
A: The purpose of QME Form 123 is to disclose any potential conflict of interest on the part of the Qualified Medical Evaluator (QME) and provide the injured worker with an opportunity to object or waive the evaluator based on that conflict.
Q: Who needs to fill out QME Form 123?
A: The Qualified Medical Evaluator (QME) needs to fill out QME Form 123.
Q: What happens if there is a conflict of interest?
A: If a conflict of interest is identified, the injured worker has the right to object to the evaluator or waive the conflict.
Form Details:
- Released on February 1, 2009;
- The latest edition provided by the California Department of Industrial Relations - Division of Workers' Compensation;
- Easy to use and ready to print;
- Quick to customize;
- Compatible with most PDF-viewing applications;
- Fill out the form in our online filing application.
Download a fillable version of QME Form 123 by clicking the link below or browse more documents and templates provided by the California Department of Industrial Relations - Division of Workers' Compensation.
Download QME Form 123 Qme or Ame Conflict of Interest Disclosure Form and Objection or Waiver - California
1
2
