Fillable Notice of Agreement to Limit the Scope of (Colorado DORA)

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Notice of Agreement to Limit the Scope of (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 LABOR AND EMPLOYMENT
DIVISION OF WORKERS' COMPENSATION
Notice of Agreement to Limit the Scope of the
Division Independent Medical Examination (DIME)
Requesting Party: Claimant Carrier
WC#: Claimant Name:
Both parties hereby notifying the DIME Physician to LIMIT THE SCOPE OF THE DIME on the following
issues:
Maximum Medical Improvement
Permanent Impairment
Apportionment
List any specic part(s) of the body and/or conditions NOT TO BE EVALUATED by the DIME Physician:
We hereby certify that the above statements are true and correct to the best of our knowledge.
Requesting Party Signature Date
Non-Requesting Party Signature Date
CERTIFICATE OF MAILING
By checking this box, it is certified that a copy of this document will be attached to the medical record
package served to the DIME Physician, next to the dated cover sheet and the chronological index. The parties
will also provide a copy of the agreement to the Division IME Unit.
WC200 Rev 10/18
Page 1 of 1
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Notice of Agreement to Limit the Scope of (Colorado DORA)

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Completed 27 January 2021

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