Form 123 - Qme Or Ame Conflict Of Interest Disclosure Form - California Division Of Workers' Compensation
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1
2STATE OF CALIFORNIA
Division of Workers’ Compensation – Medical Unit
P.O. Box 71010, Oakland, CA 94612
(510) 286-3700 or 1 (800) 794-6900
QME or AME Conflict of Interest Disclosure Form
QME/AME Name:
Injured Employee Name:
Employer/Insurer/TPA Claims Administrator:
Claim No.:
WCAB Case No. (if known)
QME Panel No. (if applicable):
Date Scheduled for Medical/Legal Examination:
NOTICE TO THE PARTIES:
(check appropriate box)
I, the undersigned evaluator, have determined I have a disqualifying conflict of
interest as defined in section 41.5 of the QME regulations (8 Cal. Code Regs.) in this
case.
Person/Entity with whom conflict exists:
Category of Conflict:
________ familial
(check one or more)
________ professional
________ significant financial
________ other (describe):
I have reviewed the information sent by
regarding an alleged conflict of interest. I do not believe that any disqualifying
conflict of interest, as defined in 8 Cal. Code Regs. § 41.5, exists.
I declare under penalty of perjury of the laws of California that the foregoing is true and
correct to the best of my knowledge. Signed this day :
(MM/DD/YYYY)
______________________________
_______________________________________
(Print Name)
(Signature)
Objection or Waiver By Represented Parties
:
__________
I wish to
Object to the Evaluator due to the conflict
(check one)
__________
Waive the conflict and continue using the
QME/AME in this case in spite of this
conflict.
______________________
(Date signed)
_____________________________
(Print Name of Party or Attorney Signing)
(Signature)
If form signed by attorney, name of party:
…..over/
QME Form 123 Rev Aug 2007 June 2008
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