Fillable Notice and Proposal and Application for a Division (Colorado DORA)

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Notice and Proposal and Application for a Division (Colorado DORA)

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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
Claimant Carrier
Date of Injury: Need for Interpreter? Yes No
Phone #:
State: Zip:
Phone #:
Phone #:
Phone #:
1. Requesting party:
2. WC#:
Claimant’s Name:
Email:
Claimant’s Address:
City:
3. *Claimant’s Attorney:
Email:
Address:
4. Carrier:
Adjuster Name:
Email:
Address:
5. *Carrier’s Attorney:
Email:
Address:
6.
7. 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.
Phone #:
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.
*If the claimant and/or insurer is/are represented by an attorney, all Division correspondence will be issued only to the
attorney(s) listed.
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)
WC77 Rev 10/18
Page 1 of 4
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 specic 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.
Region 1: Upper Extremity
Right Left
Hand
Wrist
Elbow
Shoulder
Carpal Tunnel
CRPS
Thoracic Outlet Syndrome (TOS)
Region 4: Spine
Cervical
Thoracic
Lumbar
Pelvis
Sacroiliac Joint
Region 2: Lower Extremity
Right Left
Foot
Ankle
Knee
Hip
CRPS
Region 3
Psychological
Traumatic Brain Injury (TBI)
Region 5: Ear, Nose and Throat (ENT)
Ear (Hearing)
Face
Temporomandibular Joint (TMJ)
Vestibular Disorder
Nose and Throat
Region 6: Other
Digestive Skin
Hernia Urinary & Reproductive
Cardiovascular Respiratory/Pulmonary
Hematopoietic Visual
Endocrine
Total Number of Regions Checked:
WC77 Rev 10/18
Page 2 of 4
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 conict of interest when selecting.
Physician Name
Physician Address
(Street Address, City, State and Zip) MMI Date
% Rating
(WP or Extremity)
WC77 Rev 10/18
Page 3 of 4
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 ve (5) years after the date of injury and/or three (3) or four (4)
body regions.
$2,000
If ve (5) or more years after the date of injury and/or ve (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.
6. 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:
By: ___________________________________________________________________________________
Signature of Requesting Party
___________________________________________________________________________________
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/pacic/cdle/division-independent-medical-exam-dime
Print Name
WC77 Rev 10/18
Page 4 of 4
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Notice and Proposal and Application for a Division (Colorado DORA)

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Completed 27 January 2021

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