Qme Form 122 - Ame Or Qme Declaration Of Service Of Medical

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State of California 
DIVISION OF WORKERS’ COMPENSATION – MEDICAL UNIT 
AME or QME Declaration of Service of Medical - Legal Report (Lab. Code § 4062.3(i))
Case Name:_________________________________ v _______________________________________________
(employee name)
(claims administrator name, or if none employer)
Claim No.:_______________________
EAMS or WCAB Case No. (if any):___________________
I, ____________________________________________________________________________, declare:
(Print Name)
1. I am over the age of 18 and not a party to this action.
2. My business address is:_________________________________________________________________
3. On the date shown below, I served the attached original, or a true and correct copy of the original,
comprehensive medical-legal report on each person or firm named below, by placing it in a sealed
envelope, addressed to the person or firm named below, and by:
A
depositing the sealed envelope with the U. S. Postal Service with the postage
fully prepaid.
B
placing the sealed envelope for collection and mailing following our
ordinary business practices.
I am readily familiar with this business’s
practice for collecting and processing correspondence for mailing. On the
same day that correspondence is placed for collection and mailing, it is
deposited in the ordinary course of business with the U. S. Postal Service in
a sealed envelope with postage fully prepaid.
C
placing the sealed envelope for collection and overnight delivery at an office
or a regularly utilized drop box of the overnight delivery carrier.
D
placing the sealed envelope for pick up by a professional messenger service
for service. (Messenger must return to you a completed declaration of
personal service.)
E
personally delivering the sealed envelope to the person or firm named below
at the address shown below.
Means of service:
Date Served:
Addressee and Address Shown on Envelope:
(For each addressee,
enter A – E as appropriate)
____________________
________
____________________________________________________
____________________
________
____________________________________________________
____________________
________
____________________________________________________
____________________
________
____________________________________________________
I declare under penalty of perjury under the laws of the State of California that the foregoing is true and
correct.
Date: _________________________________________
___________________________________________
______________________________
(signature of declarant)
(print name)
QME Form 122
Rev. February 2009

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