Fill and Sign the Co Proposal Form

COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT DIVISION OF WORKERS’ COMPENSATION NOTICE AND PROPOSAL TO SELECT AN INDEPENDENT MEDICAL EXAMINER Complete Sections I and II. Please read the information at the bottom of this form SECTION I Notice and Proposal of Independent Medical Examiner WC # Carrier Claim # Social Security # Claimant Name Date of Injury I , the (check one) . □ claimant □ respondent, disagree with the determination by Dr. , dated , and I request a Division IME. I understand that the Division IME will consider the issues of MMI, permanent impairment and apportionment, if relevant. I propose any one of the following physicians to conduct the IME: ( The physician must be Level II accredited.) A list of accredited physicians, as well as other information and forms, is available on the Division’s web site. You may also call the Customer Service Unit listed below. I understand that I need to talk to the other party to discuss this request. Once the negotiation process is completed, I must submit the Application for IME form to the Division and all parties. Signature of Requester Phone # □ *Check here if you claim to be unable to pay [indigent] the cost of the IME. See Instruction No. 7, below. SECTION II Certificate of Mailing Copies of this document were placed in the U.S. mail or delivered to the following parties this day of , List the names and address of all persons copied: Name Address Claimant: Claimant’s Attorney: Carrier: Carrier’s Attorney: Division of Workers’ Compensation, 633 17 th. St., Suite 400, Denver, CO 80202-3660 By: Signature INFORMATIONAL SUMMARY The following is a brief outline of the Division Independent Medical Examination (IME) process. This general information may not include all circumstances and is not meant as legal advice. Also refer to Rule 11. If you have any questions, contact the Customer Service Unit listed below. 1. The party requesting the IME (requester) must complete the Notice and Proposal for Independent Medical Examiner form. The requester must send this Notice to the other party. If you are the claimant, the other party is the insurance carrier. If you are the Insurance Carrier, the other party is the claimant or claimant’s representative, if applicable. 2. The parties have 30 calendar days to negotiate the selection of the Independent Medical Examiner (physician who will conduct the IME). The requester needs to obtain an Application for Independent Medical Examination (IME), Form WC77, during this time. 3. If the parties agree on the Independent Medical Examiner, the requester must schedule the examination promptly with the physician. The requester must also complete the Application for IME form and submit this to the Division of Workers’ Compensation, the physician, and the other party. 4. If the parties do not agree on the Independent Medical Examiner, or there is no response to the Notice and Proposal, the insurance carrier must complete the Notice of Failed IME Negotiation, Form WC165. A copy must be sent to the Division and the claimant. a. The party requesting the IME shall have 30 days from the date of the failure to agree or respond to submit an Application for Independent Medical Examination (IME), Form WC77. Within 10 calendar days of receiving the Application, the Division will designate a panel of three qualified physicians from which the parties must select one physician pursuant to procedures stated in Rule 11-3. The parties will be notified in writing of the three-physician panel. b. The requesting party has 7 business days to strike one name from the list and notify the other party. The opposing party then has 5 business days to strike another name, and notify the Division’s IME unit and the requesting party of the remaining name. c. If the parties do not complete this process in 15 business days, the Division will select one name and notify the parties. Within 5 business days of the physician selection, the requesting party must telephone the physician and schedule the examination. 5. The carrier must submit medical records to the physician and other party at least 14 calendar days before the examination. 6. The claimant must notify the carrier if a language interpreter is needed at least 14 calendar days before the examination. The requester is responsible for paying the interpreter. 7. The requester must make the payment to the IME physician at least 10 calendar days before the examination. If you wish to assert that you are unable to pay for the IME, you must obtain and file an “Application for Indigent Determination (IME)”, Form WC35 IME, within 20 days of the filing of this Notice and Proposal. Contact the Division Customer Service Unit or IME Unit to obtain the form or for further information. 8. The physician is required to mail the IME report to the parties and the Division within 20 calendar days of the examination. 9. If the requester wishes to cancel the IME process, contact the IME Section of the Division immediately. If you have any questions, or need an Application for Independent Medical Examination (IME), Form WC77, or any other forms, contact the Division of Workers’ Compensation Customer Service Unit at 303.318.8700 or toll free at 888.390.7936 WC146 Rev. 01/06 Page 1 of 2 (The top portion may be used for mailing purpose. This side of the form is optional.) NOTICE AND PROPOSAL TO SELECT AN INDEPENDENT MEDICAL EXAMINER Form WC146 WC146 Rev. 01/06 Page 2 of 2