Fillable Request for Appointment to the Division Independent Medical (Colorado DORA)

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Request for Appointment to the Division Independent Medical (Colorado DORA)

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COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT
DIVISION OF WORKERS' COMPENSATION
633 17th St., Suite 400, Denver, CO 80202-3626
303.318.8655
Request for Appointment to the
Division Independent Medical Examination Panel (DIME)
Please Print or Type
Date of Application: _______/________/________
Personal Identification
Last Name: First Name: MI:
Office Address: City: Zip:
State:
Colorado Professional License No.: Office Phone: Fax:
( ) ( )
Degree: Specialty:
If you are a medical doctor or a doctor of osteopathy, complete the following:
Currently Board Certified by the American Board of Medical Specialties or the American Osteopathic Association?
Yes No Date: / /
Currently Board Eligible for specialty certification by the American Board of Medical Specialties or the American
Osteopathic Association?: Yes No
If yes, Board certified or eligible, name of Board:
Documentation of Board Certification or eligibility in field of specialty
must accompany this application.
Do you intend to do impairment ratings?
Yes
No
If yes, Level II Accreditation is necessary.
Have you had more than 384 hours of direct patient care (excluding medical/legal evaluation) as part of your practice
within the last calendar year OR engaged in at least 384 hours of direct patient care (excluding medical/legal
evaluation) during the previous five years and demonstrated additional competency in the field of disability evaluation
through certification by the American Board of Independent Medical Examiners, the International Academy of
Independent Medical Evaluators, or equivalent continuing medical education courses?
I certify that as of the date of this application my Colorado medical license is active, with no limitations or restrictions. I
will notify the DIME Unit and withdraw from the DIME panel should any restrictions be imposed.
Yes No
Yes
No
WC076 Rev 10/18
Page 1 of 2
Clear Entire Form
CERTIFICATION
I request approval as an independent medical examiner. I will provide independent and
objective medical decisions in all cases that come before me. I will decline a request to conduct an
independent medical examination if I have a conflict of interest for any reason. I agree to
conduct a Division Independent Medical Examination between 45 and 75 calendar days from request.
I agree to submit a report to the Division and both parties as marked on the DIME Application within 20
calendar days of the examination of the claimant. This report will include the DIME
Examiners Worksheet, my written report, and the applicable AMA Guides worksheets. I
understand my performance will be measured by the quality of my examination and reports, and
not by whether my recommendations are perceived as favorable or unfavorable to the parties involved.
I have read and understand all of Rule 11, which describes the Division Independent Medical
Examination program.
I accept that examinations performed for the Division of Workers’ Compensation are paid according to
fees set by the Division of Workers’ Compensation.
________________________________________
Signature
_________________/________/______________
Date
Subscribed before me this ________________ day of ________________________, _____________.
________________________________________
Notary Public
SEAL
Address:
My Commission Expires: ___________________
WC076 Rev 10/18
Page 2 of 2
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Request for Appointment to the Division Independent Medical (Colorado DORA)

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Completed 27 January 2021

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