Colorado > Workers Comp
Division IME Physician Summary Disclosure Form (Claimant) WC180 - Colorado
| Division IME Physician Summary Disclosure Form (Claimant) Form. This is a Colorado form and can be used in Workers Comp . |
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COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT DIVISION OF WORKERS' COMPENSATION Division IME Physician Summary Disclosure Form (Claimant) WC#: Name of Claimant: Claimant address: Physician name: Physician address: Instructions: Pursuant to C.R.S. 8-42-107.2(3.5)(a) and Workers' Compensation Rule of Procedure 11-3, upon request of an interested party a physician on the Division IME panel shall provide to the Division IME Unit a list of business, financial, employment, and/or advisory relationships between a listed physician and the claimant who is a party to the claim. This summary disclosure shall be provided to the Division within 7 business days of the date of the notice of such request. I. I or my affiliated entities have the following business, financial, employment or advisory relationship with the above-named claimant: Signed: WC 180 6/2010 Dated: American LegalNet, Inc. www.FormsWorkFlow.com
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