Request Or Notification For Follow Up IME {WC178}

Instructions: This form must be submitted by the when a claimant previously had a DIME and was determined to be 221not at MMI222 and is now requesting a follow-up DIME. Per Rule 11, a follow-up DIME examination shall be scheduled with the same DIME , unless he or she is unavailable or declines to perform the examination.If the previous DIME is unable to perform the follow-up examination please notify the DIME Unit using this form.In the instance where the parties agree upon a new DIME , the parties shall indicate the name of the new DIME the agreed upon fee. Agreed upon follow-up DIMEs must use this form and the agreement shall be signed by the new DIME and all parties to the claim. If the parties have agreed upon the previous DIME under 11-4(A)(2)(a)(i) but now wish to proceed under section 11-4(A)(5), the parties shall request a prehearing conference beforean ALJ. Absent an agreement of the parties and the DIME , or an order from an ALJ, the shall pay anyadditional examination fees. Check the box that is applicable: 1. 2. 3. revious DIME will perform the follow-up examination. Division of Workers222 CompensationDIME Unit DIME Unit Email: imeunit@state.co.us DIME Unit Fax: 303-318-8659 ClaimantAttorney: Attorney:DIME Physician: American LegalNet, Inc. www.FormsWorkFlow.com