Application For A Division Independent Medical Examination (IME) {WC77}

COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT Notice and Proposal and Application for a Division Independent Medical Examination (DIME)I.Notice and Proposal þ Claimant þ þ Carrier Date of Injury: þ Need for Interpreter? þ þ Yes þ þ No Phone #: þ þ þ State: þ þ Zip: þ Phone #: þ Phone #: þ Phone #: þ Requesting party:WC#:Claimant222s Name:Email:Claimant222s Address:City:*Claimant222s Attorney:Email:Carrier:Adjuster Name:Email:*Carrier222s Attorney:Email: Phone #: *If the claimant and/or insurer is/are represented by an attorney, all Division correspondence will be issued only to theattorney(s) listed. American LegalNet, Inc. www.FormsWorkFlow.com COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT II.Application for a Division Independent Medical Examination (DIME) 1. WC#: Date of Injury: þ Claimant Name: en-USMedical Reason for DIME 2. en-USa) The Physician will consider the issues ofen-US en-USMaximum Medical Improvement, Permanent Impairment,en-USand Apportionment.en-USen-USbe deemed incomplete unless all of the checked areas are addressed. en-USen-USen-USLeften-USHand en-USWrist en-USElbow en-USShoulder en-USCarpal Tunnel en-USCRPS en-USThoracic Outlet Syndrome (TOS) en-US þ Cervical þ Thoracic þ Lumbar þ Pelvis Sacroiliac Joint en-USen-USen-USLeften-USFoot en-USAnkle en-USKnee en-USHip en-USCRPS en-US þ Psychological Traumatic Brain Injury (TBI) en-US Ear (Hearing) þ Face Temporomandibular Joint (TMJ) Vestibular Disorder Nose and Throat en-US þ Digestive þ Skin þ Hernia Urinary & Reproductive þ Cardiovascular þ Respiratory/Pulmonary þ Hematopoietic þ Visual þ Endocrine en-US American LegalNet, Inc. www.FormsWorkFlow.com 3. en-USen-US (The location in which the claimant resides may takeen-USprecedence over the preferred location): en-US 4. en-USMedical Provider Historyen-USList the name AND address of each physician who has evaluated or treated the claimant for this and/oren-USany other medical condition or injury. If a physician assigned an MMI date or an impairment rating, listen-USthe information. At least one MMI date must be listed for the DIME to proceed. Attach additional pages,en-US en-USPhysician Nameen-USPhysician Addressen-US en-US(Street Address, City, State and Zip)en-USMMI Dateen-US% Ratingen-US(WP or Extremity) American LegalNet, Inc. www.FormsWorkFlow.com 5. en-USen-USen-US box only. en-USIf less than two (2) yearsen-US after the date of injury and/or less than three (3) body regions. en-USIf two (2) or more yearsen-USen-USbody regions. en-USen-USen-USThe requesting party will be responsible for payment of the DIME to the selected physician unless an order en-USof indigence has been granted. en-USIf parties agree on a DIME physician during the negotiation process the parties shall agree upon a fee with en-USthe physician. en-US6. en-USDivision of Workers222 CompensationDIME Unit633 17th St., Suite 400Denver, CO 80202-3626DIME Unit Email: imeunit@state.co.usDime Unit Fax: 303-318-8659Claimant: Claimant222s Attorney: : 222 Attorney: By: en-US Signature of Requesting Party en-USIf you have any questions about the DIME process, please contact the Division of Workers222 Compensation en-USCustomer Service at 303-318-8700. en-USResource:en-US American LegalNet, Inc. www.FormsWorkFlow.com