Fillable Disclosure Form Designated Health Care Provider (Colorado DORA)

Fill Online, Printable, Fillable, Blank Disclosure Form Designated Health Care Provider (Colorado DORA) Form

Use Fill to complete blank online COLORADO DORA pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Disclosure Form Designated Health Care Provider (Colorado DORA)

On average this form takes 8 minutes to complete

The Disclosure Form Designated Health Care Provider (Colorado DORA) form is 4 pages long and contains:

  • 0 signatures
  • 0 check-boxes
  • 33 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your DORA forms online.

Colorado Department of Regulatory Agencies (DORA) is responsible for professional licensing and consumer protection in Colorado USA.

BROWSE COLORADO DORA FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
1
Instructions for Completing the
Designated Health Care Provider
Disclosure Form
Please read all pages
This form is “fillable.” That means you can type the information onto
the form from your computer and print the form. You will not be able
to save the form onto your computer’s hard drive.
When you open the form, click in the “Claimant” box (field), complete
the information, and use the tab key to navigate to the next field. Do
not use the Enter
key; pressing the Enter key will only page down.
Each field has been limited. This means that you cannot continue to
type information into a field if it doesn’t fit into the space provided.
Use numbers only
to fill in the fields for phone number and dollar
amounts. Do not use dashes, parentheses or dollar signs; when you
tab out of the field, it will fill in automatically. If a dollar amount
contains cents, do
type the period. To fill in a check box, click inside
the box with your mouse.
To clear or delete all the information you have typed onto the form,
click on the red “
Clear Entire Form” button. To clear all information on
a single page, click on the red “Clear This Page” button. To change
the information in one field, use the backspace or delete key.
Go to Form
2
“Clear Entire Form” button
Clears all information at once
“Clear This Page” button
Clears all information off an
individual page
COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT
DIVISION OF WORKERS’ COMPENSATION
Designated Health Care Provider Disclosure Form
Provider name:
Provider address:
Instructions:
Pursuant to §8-43-404 (5)(a)(I)(A) and Workers’ Compensation Rule of
Procedure 8-3, upon request of an interested party, a designated provider shall
provide a list of ownership interests and employment relationships to the
requesting party within 5 days of such request. The information in this form must
be updated when there is a change so that it is current to within 30 days of the
date of the request. Additional pages may be used if necessary.
I. I have an ownership interest in the following business or entities:
(“Ownership interest” means ownership in a business or entity that is involved in providing
medical care and through which the physician can exercise direction and control.)
II. I have employment relationships or perform medical services for the
following interests:
(Employment relationships include any and all relationships in which the undersigned is in an
employer/employee relationship to perform medical services in exchange for remuneration.)
Signed: Dated:
WC 30 11/07 Page 1 of 2
Clear Entire Form
Clear This Page
Back to Instructions
Go To Page 2
CERTIFICATE OF MAILING: Copies of this document were placed in the U.S. mail or delivered to the
following parties this day of , .
Day
Month
Year
List the names and addresses of all persons copied:
By:
Signature
WC 30 11/07 Page 2 of 2
Clear This Page
Go To Page 1
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Disclosure Form Designated Health Care Provider (Colorado DORA)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 27 January 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document