Colorado
Workers Comp
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Last updated: 12/19/2024
Division IME Physician Summary Disclosure Form (Insurer Or Self-Insured Employer) {WC179}
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Description
DIVISION INDEPENDENT MEDICAL EXAMINATION (DIME) PHYSICIAN SUMMARY DISCLOSURE FORM. This form is used by physicians on the Division's IME panel to disclose any business, financial, employment, or advisory relationships they may have with insurers or self-insured employers involved in a workers' compensation case. This disclosure is required by C.R.S. 8-42-107.2(3.5)(a) and Workers' Compensation Rule of Procedure 11-3. If the physician has no such relationships to disclose, they must attest to this on the form. www.FormsWorkflow.com
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