Fillable Division Independent Medical Examination (DIME) Physician Summary Disclosure (Colorado DORA)

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Division Independent Medical Examination (DIME) Physician Summary Disclosure (Colorado DORA)

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

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COLORADO DEPARTMENT OF LAB
OR
AND EMPLOYMENT
DIVISION
OF WORK
ERS’ COMPENSATION
Division Independent Medical Examination (DIME)
Physician Summary Disclosure Form
(Insurer or Self-Insured Employer)
I.
Signed: Dated:
Physician name:
Physician address:
Instructions:
Pursuant to C.R.S. 8-42-107.2(3.5)(a) and Workers’ Compensation Rule of
Procedure 11-3, upon request of a party a physician on the Division IME panel shall
provide a list of business, financial, employment, or advisory relationship between the
listed physician and the insurer or self-insured employer involved in a case. This
disclosure shall be provided to the Division IME Unit within 7 business days of the
notice of such request. Alternatively, a completed form may be pre-submitted to the
Division IME Unit. If such form is pre-submitted, the information in this form
must be updated within 30 days of a material change in a relationship or once per
year. Additional pages may be used if necessary.
Summarize any business, financial, employment or advisory relationship you or your
affiliated entities have with insurers or self-insured employers, or alternatively supply
summary information on any business, financial, employment or advisory relationship
you may have with the insurer/self-insured employer in an identified workers'
compensation case.
WC179 Rev 10/18
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Division Independent Medical Examination (DIME) Physician Summary Disclosure (Colorado DORA)

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Completed 27 January 2021

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