QME Or AME Conflict Of Interest Disclosure Form {QME 123}

QME Form 123 - QME OR AME CONFLICT OF INTEREST DISCLOSURE FORM. This form is used by Qualified Medical Evaluators (QMEs) and Agreed Medical Evaluators (AMEs) to formally disclose any potential conflicts of interest that may affect their ability to perform an unbiased medical-legal evaluation in a California workers’ compensation case. Evaluators must indicate whether a disqualifying conflict exists under 8 CCR §41.5—such as familial, professional, or significant financial relationships—or whether they have reviewed an alleged conflict and determined none exists. The form includes space for the evaluator’s declaration under penalty of perjury and a section for represented parties to either object to or waive the conflict. www.FormsWorkflow.com