Declaration Regarding Protection Of Mental Health Record {QME 121}

QME Form 121 - DECLARATION REGARDING PROTECTION OF MENTAL HEALTH RECORD. This is a California Division of Workers’ Compensation form used by licensed medical providers to restrict an injured employee’s direct access to specific mental health records when disclosure may pose a substantial risk of adverse medical or psychological consequences. The provider must specify the medical basis for restricting access under Health & Safety Code §123115(b) and Title 8 CCR §36.5, identify the employee and claim information, and document the employee’s designated physician or qualified health care provider who may receive the records instead. The form also records how the provider responded to the employee’s request and requires tracking of future authorized release requests. It must be signed under penalty of perjury. www.FormsWorkflow.com