Fill and Sign the Ime Form

COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT DIVISION OF WORKERS' COMPENSATION Notice and Proposal and Application for a Division Independent Medical Examination (DIME) I. Notice and Proposal 1. 2. Requesting party: WC#: Date of Injury: Need for Interpreter? Claimant’s Name: Phone #: Email: Claimant’s Address: City: State: Zip: 3. *Claimant’s Attorney: Phone #: Email: Address: Carrier: Phone #: 4. Adjuster: Phone #: Email: Address: 5. *Carrier’s Attorney: Phone #: Email: Address: *If the claimant and/or insurer is/are represented by an attorney, all Division correspondence will be issued only to the attorney(s) listed. 6. I propose any one of the following physicians to conduct the DIME: ( Physician must be Level II accredited .) A list of accredited physicians, as well as other information and forms, are available at: https://www.colorado.gov/cdle/dwc. 1) 2) 3) I understand that I need to communicate to the other party to discuss this request. Once the negotiation process is completed, the Notice of DIME Negotiations form must be submitted to the DIME Unit and all parties. Notice Regarding PAYMENT FOR DIME: I hereby certify that I will be responsible for payment of the DIME to the DIME Physician. I understand that this payment MUST be made prior to scheduling and within 14 days after receiving the DIME Physician Confirmation Letter. Claimant, if you believe that you are unable to pay the fee(s) required to obtain a DIME, you must complete and file the Application for Indigent Determination within 15 days of submitting this Notice and Proposal. Once an order with the determination has been issued by an Administrative Law Judge, the party responsible for payment is required to do so within 10 days of the Order. Should you have any questions, please call Customer Service at 303-318-8700.7. WC77 Rev 10/18 Page 1 of 4 Claimant Carrie r Yes N o COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT DIVISION OF WORKERS' COMPENSATION II. Application for a Division Independent Medical Examination (DIME) 1. WC#: Date of Injury: Claimant Name: Medical Reason for DIME 2. a) The Physician will consider the issues of Maximum Medical Improvement, Permanent Impairment, and Apportionment. b) Check specific Region(s) and part(s) of the body and/or conditions to be evaluated. The report will be deemed incomplete unless all of the checked areas are addressed. Total Number of Regions Checked: WC77 Rev 10/18 Page 2 of 4Region 4: Spine Region 5: Ear, Nose and Throat (ENT) Cervical Ear (Hearing) Thoracic Face Lumbar Temporomandibular Joint (TMJ) Pelvis Vestibular Disorder Sacroiliac Joint Nose and Throat Region 6: Other Digestive Skin Hernia Urinary & Reproductive Cardiovascular Respiratory/Pulmonary Hematopoietic Visual Endocrine 3. Preferred geographical location of examination. (The location in which the claimant resides may take precedence over the preferred location): Physician Selection Process 4. Medical Provider History List the name AND address of each physician who has evaluated or treated the claimant for this and/or any other medical condition or injury. If a physician assigned an MMI date or an impairment rating, list the information. At least one MMI date must be listed for the DIME to proceed. Attach additional pages, if needed. The DIME Unit uses this information to assure there is no conflict of interest when selecting. WC77 Rev 10/18 Page 3 of 4Physician Name Physician Address (Street Address, City, State and Zip) MMI Date % Rating (WP or Extremity) 5. PAYMENT for DIME: Check ONE box only. $1,000 If less than two (2) years after the date of injury and/or less than three (3) body regions. $1,400 If two (2) or more years but less than five (5) years after the date of injury and/or three (3) or four (4) body regions. $2,000 If five (5) or more years after the date of injury and/or five (5) or more body regions. The requesting party will be responsible for payment of the DIME to the selected physician unless an order of indigence has been granted. If parties agree on a DIME physician during the negotiation process the parties shall agree upon a fee with the physician. 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 U nit Email: imeunit@state.co.us | Dime Unit Fax: 303-318-86596. Claimant: Claimant’s Attorney: Carrier: Carrier’s Attorney: By: Signature of Requesting Party Print Name If you have any questions about the DIME process, please contact the Division of Workers’ Compensation Customer Service at 303-318-8700. Resource: https://www.colorado.gov/pacific/cdle/division-independent-medical-exam-dime WC77 Rev 10/18 Page 4 of 4