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) 1. 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): 2. 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 1 American LegalNet, Inc. www.FormsWorkflow.com 6. The employee has designated the following physician, within the definition of Labor Code § 3209.3 or a health care provider as defined in Health and Safety Code § 123105, for alternate service of the employee's copy of this record: Name: Address: Phone: Medical license no. (CA, if known): Date of employee designation of this physician or health care provider: (MM/DD/YYYY) 7. For the above reasons, in response to the employee's request of _____________________(date MM/DD/YYYY) for a copy of the record, I responded in the following manner: (Check one below, as appropriate.) I declined to allow the employee to personally inspect or receive a copy of the record. I declined to allow the employee to personally inspect, receive a copy or to be served personally with a copy of the record. However, at the employee's request, I did provide to, or serve a copy of the record on, the physician or health care provider designated by the employee as noted below: Name: Address: Phone: Date of Service: Manner of Service: (mail, overnight mail, courier, fax) 8. From this time forward, I shall note in the medical file for this employee each time any licensed physician, within the definition of Labor Code 3209.3 or a health care provider as defined in Health and Safety Code § 123105, requests to inspect or copy this record on behalf of the employee. I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Date signed: Fax: Fax: (Signature) Address: (Print name) Phone: File record of requests for copies of the attached record made subsequent to the declaration date above: Date Person License type and License number QME Form 121 Rev. February 2009 2 American LegalNet, Inc. www.FormsWorkflow.com