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 is provided upon request of a party to a Division IME. It is a summary disclosure of any business, financial, employment, or advisory relationship between the listed IME physician and [the |
| Claimwire Description | n/a |