How to Fill Out California QME Form 122: Declaration of Service

California QME Form 122 is the one-page Declaration of Service of Medical-Legal Report that a Qualified Medical Evaluator or Agreed Medical Evaluator attaches to an evaluation report to prove every required party received it. You complete the form on the day you serve the report, sign it under penalty of perjury, and keep the signed original in the file. The blank form is free from the Division of Workers’ Compensation forms page at dir.ca.gov/dwc/forms.html, or by calling 1-800-794-6900.¹

When You Use Form 122 and When You Don’t

Form 122 is the service declaration for cases where the injured worker has an attorney. Under 8 CCR Section 36, the evaluator completes Form 122, attaches it to the comprehensive medical-legal report, and serves the package on the injured worker, the worker’s attorney, and the claims administrator (or the employer, if there is no claims administrator). It applies to initial reports, follow-up reports, and supplemental reports alike.²

If the worker is unrepresented, you don’t use Form 122 at all. You use Form 111, the Findings Summary Form, which combines the service declaration with a summary of the evaluator’s conclusions. Attaching Form 122 to an unrepresented case, or Form 111 to a represented one, creates a service defect that can delay the claim.²

How to Fill Out Each Section

The form is short, but every field is signed under penalty of perjury, so accuracy matters.³

Case Identification

At the top, enter the date of service, the case name formatted as “Employee Name v. Claims Administrator Name” (or the employer’s name if no claims administrator is involved), the claim number, and the EAMS or WCAB case number if one has been assigned. Leave the WCAB field blank if no case number exists yet.

Declarant Information

Print the full name of the person who actually performed the service. This does not have to be the evaluating physician — a staff member commonly handles it — but the declarant must be over 18 and not a party to the case. Enter the declarant’s business address below the name.

Method of Service

The form assigns a letter to each of the five allowed service methods. You’ll enter the matching letter next to each recipient in the service table below.

A. U.S. mail. You deposited the sealed envelope with the Postal Service, postage fully prepaid.
B. Office mail collection. You placed the envelope for collection through your ordinary business practices, and it was deposited with the Postal Service that same day.
C. Overnight carrier. You dropped the envelope at an office or drop box of an overnight delivery service.
D. Messenger service. A professional messenger picked up and hand-delivered the envelope, and the messenger returned a completed declaration of personal service to you.
E. Personal delivery. You personally handed the envelope to the recipient at the address listed.

Service Table

Record each recipient on a separate row with the date served, the service method letter (A through E), and the addressee’s name and address exactly as shown on the envelope. A standard represented case needs at least three rows: the injured worker, the worker’s attorney, and the claims administrator or employer.

Signature

The declarant signs and prints their name beneath the statement: “I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.” An unsigned form is not a valid declaration of service.³

Who Has to Receive the Report

In a represented case, three parties must be served on the same day: the injured worker, the worker’s attorney, and the claims administrator (or employer if none). Each gets its own row on Form 122.²

Missing even one recipient creates incomplete service, which can stall the case or give the other side grounds to challenge the report’s admissibility. If a party moves or changes attorneys, use the most recent address on file.

Deadline for Serving the Report

Form 122 has no independent filing deadline. It goes out with the report, and the report has its own clock. Under 8 CCR Section 38, an initial or follow-up comprehensive medical-legal evaluation report must be prepared and served within 30 days after the evaluator examines the injured worker or otherwise begins the evaluation.⁴

If the evaluator cannot meet the 30-day deadline, usually because test results or a consulting physician’s report has not arrived, the evaluator may request up to 30 additional days from the Medical Director using Form 112. A separate 15-day extension is available for narrowly defined good cause, such as a medical emergency involving the evaluator’s family, a death in the family, or a natural disaster that interrupts the office.⁴

Supplemental reports run on a longer timeline: 60 days from the date a party sends a written or electronic request, and the parties can agree in writing to extend that by up to 30 days without involving the Medical Director. Missing any of these deadlines can cost the evaluator the fee for the report, unless both sides waive their right to a new evaluation.⁴

When Electronic Service Replaces Form 122

If all parties agree in writing to accept electronic delivery, the evaluator may serve the report electronically under 8 CCR Section 36.7. In that case, you do not use Form 122. You prepare an Affidavit of Proof of Electronic Service instead, which must include:

The name and business address of the person performing the electronic service
A statement that the person is over 18 and employed in the county where the service occurs
A statement that the person is familiar with the business’s electronic service practices
The electronic service address and business address of the person sending the report
The date of service
The name and electronic service address of each person served
A statement confirming the document was served electronically

The affidavit is signed under penalty of perjury. The evaluator still keeps an original signed copy of every document served, and a party whose email address changes is responsible for notifying the physician and the other parties. The evaluator is only required to use the most recent electronic address on file.⁵

Psyche Injury Claims Add Another Form

Disputed psyche claims follow additional requirements under 8 CCR Section 36.5. In a represented psyche case, you attach Form 121 (Declaration Regarding Protection of Mental Health Record) to the report and use Form 122 to document service on the worker’s designated physician, the worker’s attorney, and the claims administrator’s attorney (or the claims administrator directly, if none). In an unrepresented psyche case, once you receive a completed Form 120 (Voluntary Directive for Alternate Service) from the worker, you attach the original Form 120 to the report and use Form 111 rather than Form 122.⁶ Getting the form combination wrong in a psyche case can expose confidential treatment records that should have been shielded.

What Goes Wrong If Service Is Sloppy

Under 8 CCR Section 51, the Administrative Director may deny reappointment to a QME who has repeatedly failed to follow the report-service regulations.⁷ A report that was not properly served may also face admissibility challenges before the Workers’ Compensation Appeals Board, because proof of service is what establishes that every party had the chance to review and respond.

The more common consequence, though, is delay. If a party claims it never received the report and you cannot produce a properly completed Form 122, you may need to re-serve the report and restart the opposing party’s response clock. Keep the signed original in the file, match the addresses on the form to what appears on the envelopes, and confirm every required recipient has a row before the report goes out.

1
New York Codes, Rules and Regulations. 8 CCR 122 – AME or QME Declaration of Service of Medical-Legal Report
2
Department of Industrial Relations. California Code of Regulations Title 8 Section 36 – Service of Comprehensive Medical-Legal Evaluation Reports by Medical Evaluators
3
Department of Industrial Relations. QME Form 122 – AME or QME Declaration of Service of Medical-Legal Report
4
Department of Industrial Relations. California Code of Regulations Title 8 Section 38 – Medical Evaluation Time Frames and Extensions for QMEs and AMEs
5
New York Codes, Rules and Regulations. 8 CCR 36.7 – Electronic Service of Medical-Legal Reports by Medical Evaluators
6
Cornell Law Institute. California Code of Regulations Title 8 Section 36.5 – Service of Comprehensive Medical-Legal Report in Claims of Injury to the Psyche
7
Department of Industrial Relations. California Code of Regulations Title 8 Section 51 – Reappointment and Denial of Reappointment