Fill and Sign the Ime 497300813 Form

WC132 Rev 12/18 Page 1 of 2COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT DIVISION OF WORKERS' COMPENSATION DIME Examiner's Summary Sheet 1. Claimant Name: 2. DIME Physician: 3. Is the claimant at MMI for this injury? WC #: Date of Injury: Appointment Date: Report Due Date: Yes , the claimant reached MMI on (date) No , the claimant is not at MMI 4. DIME Physician’s Rating (Unapportioned Ratings) Spine % WP Extremities Right upper extremity % UE Convert to WP % WP Left upper extremity % UE Convert to WP % WP Right lower extremity % UE Convert to WP % WP Left lower extremity % UE Convert to WP % WP Psychological % WP Other % % WP Final Combined Unapportioned Impairment Rating % WP Final Combined Apportioned Impairment Rating (*Desk Aid #14, Apportionment Calculation Worksheet must be attached) * % WP 5. Signature Date REMEMBER TO ADDRESS ALL ISSUES ON THE DIME APPLICATION This form, your narrative report, and applicable worksheets must be completed. Send the report to the Division with copies to both parties (or their attorneys) within 20 calendar days from the appointment date. WC132 Rev 12/18 Page 2 of 2Issued October 2008 APPORTIONMENT OF IMPAIRMENT Guideline for Accredited Physicians – Injuries pre-and post- 7/1/2008 Changes per Senate Bill 08-241 and Workers’ Compensation Rule 12-3 Calculate impairment for this work-related injury (no apportionment) Deduct past impairment from current total WC132 Rev 12/18 Page 2 of 2MEDICAL RECORDS OR OTHER OBJECTIVE EVIDENCE SUBSTANTIATES PRE-EXISTING IMPAIRMENT Apportioned rating (1) ‘Disabled’ requires information that the prior injury was identified, treated, and independently disabling at the time of the current injury. ‘Disability’ is expected to include conditions which adversely impact the claimant’s ability to perform his job, or limits the claimant’s access to other jobs. Permanent work restrictions would generally fall in this category.Previous Work-related injury Current Injury Before July 1, 2008Current Injury After July 1, 2008 Calculate and clearly state current total impairment rating including past impairmentPatient was disabled prior to and at time of current injury (1)Previous Non-work- related injury identified & treated Patient not disabled