Voluntary Directive For Alternate Service Of Medical Legal Evaluation Report
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STATE OF CALIFORNIA
DEPARTMENT OF INDUSTRIAL RELATIONS
DIVISION OF WORKERS’ COMPENSATION
MEDICAL UNIT
MAILING ADDRESS:
P. O. Box 71010
Oakland, CA 946123
(510) 286-3700 or (800) 794-6900
Fax: (510) 622-3467
VOLUNTARY DIRECTIVE FOR ALTERNATE SERVICE OF MEDICAL-LEGAL
EVALUATION REPORT ON DISPUTED INJURY TO PSYCHE
(Unrepresented Employees Only)
Injured Employee Name:
Date of Injury:
Claim No.:
EAMS or WCAB Case No.:
Claims Administrator:
Name of QME:
Date of Evaluation Exam:
I,____________________________________________________________________________,
(print name of injured employee)
understand I have a right to be served with a copy of the medical-legal evaluation report written
about my case by the QME physician named above, at the same time as a copy of the report is sent
to the claims administrator and/or the Disability Evaluation Unit.
By signing below, I hereby direct that the QME serve my copy of the medical/legal report in
the following manner:
(Check one)
By sending my copy to the following physician who will review it with me and will be paid
for an office visit for this purpose by the claims administrator, or if none by my employer.
The physician I name below may be my primary treating physician in this case or any other
physician I wish to designate. At the end of that visit, the physician named below will give
me my copy of the report:
Physician Name:
Address:
City:
State:
Zip:
Phone:
Only by sending a copy to me at my address on file. I do not wish to designate a physician
to review it with me.
I am signing this directive voluntarily and of my own free will:
(Signature of Injured Employee)
Date
Original of this signed form – attach to original medical-legal report
Copies of this signed form – to injured employee, claims administrator, reviewing physician, QME
QME Form 120 (rev. February 2009)
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