California QMEs and AMEs use this form to tell the parties they have a disqualifying conflict of interest under 8 CCR 41.5, or, after reviewing a party's allegation, that no such conflict exists. In represented cases the parties then use the bottom section to object to the evaluator or to waive the conflict and keep the evaluator.
The evaluator completes the notice and signs the declaration on page 1. Each represented party or attorney completes the objection or waiver section.
Download the current version from the source each time; forms change without notice.
QME or AME Conflict of Interest Disclosure Form
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.
Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.
Within five business days of becoming aware of it. The evaluator signs QME Form 123 and mails it to the parties. If a party raises an alleged conflict, the evaluator reviews the information and answers within five business days of receiving the notice, using the same form.
A familial relationship such as a parent, sibling, spouse or cohabitant; a significant financial interest such as employment or a 5 percent ownership or income stake; professional affiliation in the same medical-legal group; or any other relationship that would make a reasonable person doubt the evaluator's impartiality.
In a represented case each party has five business days to check object or waive at the bottom, sign and serve it on the evaluator and the opposing party. A party who objects also mails the form to the DWC Medical Unit with a request for a replacement QME.