Division Independent Medical Examination (DIME) Physician Summary Disclosure Form (Insurer or Self-Insured Employer) Forms
| Form Name | Division Independent Medical Examination (DIME) Physician Summary Disclosure Form (Insurer or Self-Insured Employer) |
| Form # | WC 179 |
| Form Revision | Rev 10/18 |
| Category | Forms » Medical/Health |
| Downloads | |
| Form State | Colorado |
| Language | English |
| State Description | This form can now only be filled out online: https://na4.documents.adobe.com/public/esignWidget?wid=CBFCIBAA3AAABLblqZhARa34IXBCgwfCRJlNSOeFPP5dw-qPWjtnQWyI0SGQZqjyQv8UZaKEpdMK65L27CD4* |
| Claimwire Description | n/a |