QME Form 122: Proof of Service, Medical-Legal Report

California evaluators must serve every comprehensive medical-legal report on the parties, and this one-page declaration under Labor Code 4062.3(i) proves it was done. The declarant lists the case name, claim number and any EAMS or WCAB case number, then for each addressee the date served, the address on the envelope and the means of service, and signs under penalty of perjury.

Who completes it

The AME, QME or the staff member who actually serves the report completes and signs it; the declarant must be over 18 and not a party to the case.

Submitting and payment

How to submit it
Attach the completed declaration to the medical-legal report served on the parties.
Who pays
The form does not address fees.

Good to know

  • Means of service codes: A U.S. mail, B ordinary business mail collection, C overnight delivery, D professional messenger (who must return a declaration of personal service), E personal delivery.
  • Enter a service code and date for each addressee, using the address exactly as shown on the envelope.
  • In unrepresented cases, QME Form 111 contains its own declaration of service, including a line for service on the Disability Evaluation Unit.
  • The current version, Rev. February 2009, is a single fillable page that cites Labor Code 4062.3(i) in its title.

Get the official form

Download the current version from the source each time; forms change without notice.

AME or QME Declaration of Service of Medical - Legal Report

How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.

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Frequently asked questions

Who can sign QME Form 122?

Whoever actually serves the medical-legal report, whether the AME, the QME or a member of the evaluator's staff. The declarant must be over 18 and not a party to the action, gives a business address, and signs under penalty of perjury under California law.

What service methods does QME Form 122 allow?

Five: depositing the sealed envelope with the U.S. Postal Service, placing it for collection under the office's ordinary mailing practice, overnight delivery, pickup by a professional messenger who returns a declaration of personal service, or personal delivery to the person or firm at the listed address.

Why does a medical-legal report need a proof of service?

Labor Code 4062.3(i) requires the evaluator to serve the comprehensive medical-legal report on the parties, and the declaration documents when and how each one was served. Under Labor Code 139.2(j)(1)(A) and 8 CCR 38 the report is generally due within 30 days of the exam, and this proof shows the service date.