COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT
DIVISION OF WORKERS' COMPENSATION
Information Regarding Independent Medical Examination
• I understand that I will be going to an independent medical examination (IME).
• I understand that the IME will be done by a doctor who is not giving me treatment or care,
and that I will not have a patient/doctor relationship with this doctor. The doctor doing the
IME is being paid by the employer or the insurer in my workers’ compensation claim. The
doctor will write a report about the exam, and I will get a copy of the report.
• I understand that the doctor will ask me questions about my condition and/or medical
history, and may also look at my medical records.
• I understand that the doctor is required by law to make an audio (voice) recording of this
examination. Therefore, what the doctor says and what I say may be heard by others at a
later date and I should not have an expectation of privacy about things that are related to my
workers’ compensation claim.
• I understand that anyone involved in my claim, including me, can request a copy of the
recording, and that if anybody makes a request the recording will first be given to me. I
understand that if I say something during the examination that I believe is private and not
related to my claim, there is a way for me to try to have that part of the recording erased.
• I understand that I have 20 days after the report is sent to me to ask, in writing, for a copy of
the audio recording. I understand the doctor is allowed to charge me the fee set forth in the
Rule 18 Medical Fee Schedule for this copy. If I believe that part of the recording should be
erased, I have to say it in writing within 15 days of when the recording was sent to me. I
understand that information about the process is available by contacting the Division of
Workers’ Compensation and/or looking at its website. Anything that is mentioned in the
doctor’s written report will not be erased.
• I understand that I must be given this form, and that I must sign this form, according to a
Division of Workers’ Compensation Rule. I understand that refusing to sign this form may
be determined to be a refusal to submit to an independent medical examination, and that
such refusal could possibly impact my receipt of benefits.
• I understand that this form is intended to provide specific and limited information regarding
the IME. I can seek additional information and/or legal advice if I so choose. I can also
call the Division at 303-318-8700 or 888-390-7936 for additional information regarding
Rule 8 requirements.
_____________________________ ____________________________
Signature Print name Date
For use by a language interpreter, if necessary
I, ______________________________ (print name of interpreter) affirm that on this ____
day of ____________________, 20___, I read this document in its entirety to the individual
whose name appears above in that person’s native language, and that the person indicated an
understanding of each and every provision contained on this form.
_____________________________
Signature
