Application For A Division Independent Medical Examination (IME) {WC77}

WC77 - NOTICE AND PROPOSAL AND APPLICATION FOR A DIVISION INDEPENDENT MEDICAL EXAMINATION. This form, issued by the Colorado Department of Labor and Employment’s Division of Workers’ Compensation, is used to request and initiate the process for a Division Independent Medical Examination (DIME). It serves two main purposes. First, it acts as a notice and proposal, in which the requesting party—either the claimant or the insurer—provides details about the workers’ compensation claim, including contact information for all involved parties, relevant attorneys, and a list of proposed Level 2 accredited physicians to perform the examination. Second, it functions as an application for a DIME, identifying the specific medical issues and body parts to be evaluated in relation to the claimant’s injury. The form also includes a section to list prior medical providers who have issued Maximum Medical Improvement (MMI) dates or impairment ratings, as well as other healthcare professionals who have treated the claimant. This examination is intended to resolve disputes about MMI, permanent impairment, and apportionment in workers’ compensation cases. The form requires service to all parties and includes a certificate of service section. A base fee of $1,000 must be paid unless the claimant is deemed indigent. www.FormsWorkflow.com