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 17 State Forms found

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Notice and Proposal and Application for a Division Independent Medical Examination (DIME)

 WC77 Rev 01/15/19

Application for Indigent Determination (DIME)

WC35 Rev 10/19

Designated Health Care Provider Disclosure Form

 WC 30 11/07

Division Independent Medical Examination (DIME) Physician Summary Disclosure Form (Insurer or Self-Insured Employer)

 WC 179 Rev 10/18

DIME Examiner's Summary Sheet

 WC132 Rev 01/20

Notice of DIME Negotiations

 WC 165 Rev 12/18

NOTICE OF ONE-TIME CHANGE OF PHYSICIAN & AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION

 WC003 Rev. 06/15

Request for Appointment to the Division Independent Medical Examination Panel (DIME)

 WC076 Rev 12/18

Request to Erase (Redact) Medical Information from an Audio Recording

 WC34 08/09

Follow-Up DIME

 WC178 Rev 04/23

Authorized Treating Provider's Request for Prior Authorization

 WC 188 Rev 12/21

Information Regarding Independent Medical Examination

 WC036 Rev 12/18

Provider Compliance Agreement

WC107 Rev 02/18

Information Regarding Independent Medical Examination (Spanish)

 WC036B Rev 12/18

Notice of Reschedule or Termination of the Division Independent Medical Examination (DIME)

 WC198 Rev 04/20
Disclaimer: These forms may not be the most recent version. Colorado may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on this site. Please check official sources.
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