COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT
DIVISION OF WORKERS' COMPENSATION
Notice of DIME Negotiations
The parties must attempt to negotiate the selection of a physician to conduct the DIME. The
Notice of DIME Negotiations form shall be filed within 30 days of the filing of the Notice and
Proposal and Application for a DIME. If the parties have agreed on a DIME Physician and fee,
either party may file this form. If the parties have not agreed on the DIME Physician, the insurer shall
file the form.
WC #: Claimant Name:
Unable to agree upon a physician.
Able to agree on the physician listed below. (The Physician must be Level II accredited and may not have
previously treated the claimant at any time. If parties agree on a DIME Physician the parties shall
agree upon a fee with the physician. All parties must sign below, including the physician.)
Agreed upon DIME fee: _________________________________________________________________
Name of Physician: Phone Number:
Oce Location:
City: State: Zip:
Physician Email:
By signing below all parties agree to the DIME fees state above:
Claimant / Attorney: ____________________________________________________________________
Carrier / Attorney: ______________________________________________________________________
Agreed upon DIME Physician: ____________________________________________________________
If you have any questions about the DIME process, please contact Division of Workers’ Compensation
Customer Service at 303-318-8700.
Resource: https://www.colorado.gov/pacic/cdle/division-independent-medical-exam-dime
CERTIFICATE OF MAILING:
Copies of this document were sent to the Division and the following parties
this _______ day of _______________, ________.
List names and addresses of all persons copied:
Division of Workers’ Compensation, DIME Unit
633 17th St., Suite 400, Denver, CO 80202-3626
DIME Unit Email: imeunit@state.co.us | DIME Unit Fax: 303-318-8659
Claimant:
Claimant’s Attorney:
Carrier:
Carrier’s Attorney:
Agreed upon DIME Physician:
By:
Signature
Print Name
