Fill and Sign the Notice Ime Form

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: Office 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: 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 If you have any questions about the DIME process, please contact Division of Workers’ Compensation Customer Service at 303-318-8700. WC 165 Rev 12/18 Resource: https://www.colorado.gov/pacific/cdle/division-independent-medical-exam-dime