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Declaration Regarding Protection Of Mental Health Record

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State of California

DIVISION OF WORKERS’ COMPENSATION ‐ MEDICAL UNIT

DECLARATION REGARDING PROTECTION OF MENTAL HEALTH RECORD

(Health and Safety Code § 123115(b) and § 36.5, Title 8, California Code of Regulations)

NOTE: THE MENTAL HEALTH RECORD(S) ATTACHED TO THIS DECLARATION MUST NOT BE

SEEN BY OR COPIED BY __________________________________________________ FOR THE REASONS

(Print name of injured employee)

STATED BELOW:

I, ______________________________________________________, declare as follows:

(Print your name)

I am licensed in the state of California as a _______________________, license number _______________

(Type of license)

The attached medical record pertains to:

Employee name:________________________________________________________________________

Address: ________________________________________________________ Phone:_________________

W.C. Claim number:_____________________________________________________________________

W. C. Claims administrator:________________________________________ Phone:_________________

3. In my professional medical judgment and pursuant to Health and Safety Code § 123115(b), the attached mental

health record, or the portions of this record designated below and on the face of the record, if seen or copied by the

employee named above, will or is likely to result in a substantial risk of significant adverse or detrimental medical

consequences to the employee, including but not limited to, (describe medical basis for conclusion):

4. On _______________________________ 20____, I was asked by the above named employee, or I was required

by law,

to serve a copy of this medical record on the employee.

5. On that same date, I advised the employee that the record only could be inspected by, copied or provided to a

licensed physician, within the definition of Labor Code § 3209.3 or a health care provider as defined in Health and

Safety Code § 123105, on behalf of the employee, and that the employee must use that mechanism to obtain the

record.

QME Form 121

Rev.

February 2009

Declaration Regarding Protection Of Mental Health Record

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