Notice Of DIME Negotiations {WC165}

WC165 - NOTICE OF DIVISION INDEPENDENT MEDICAL EXAMINATION (DIME) NEGOTIATIONS. This form is used in Colorado workers' compensation cases to document the parties’ efforts to agree on a physician for the DIME process. After submitting the Notice and Proposal and Application for a DIME (WC 77), the parties have 30 days to complete and file this form. It allows them to indicate whether they were able to agree on a physician or not. If they reach an agreement, either party may file the form; if not, it is the insurer’s responsibility to do so. The chosen physician must be Level 2 accredited and must not have previously treated the claimant. The form includes space to list the physician’s name and contact information and requires signatures from both parties confirming that the doctor can evaluate the relevant body parts specified in the DIME application. A Certificate of Service section must also be completed to show that copies were properly sent to all parties, including the Division of Workers’ Compensation. www.FormsWorkflow.copm