Colorado > Workers Comp
Request Or Notification For Follow-Up IME WC178 - Colorado
| Request Or Notification For Follow-Up IME 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 INDEPENDENT MEDICAL EXAMINATION PROGRAM REQUEST/NOTIFICATION FOR FOLLOW-UP IME Instructions: This form must be submitted when the claimant previously had a Division IME and was determined to be `not at MMI,' and the insurer/respondent is now requesting a follow-up IME. Per Rule 11, to the extent possible the follow-up IME will be held with the original IME physician. If the original physician is unable to perform the follow-up, please notify the Division's IME Unit. The requesting party is responsible for payment, and also "shall pay any additional examination expense" as set forth in the Rule. If this follow-up is on a reopened claim, the facts of the specific case may determine the party responsible for requesting and paying for the exam. Do not submit this form if the follow-up is for repeat range of motion only; please notify the Division of the date and time of the appointment. WC# 1. Claimant Name 2. IME Physician Date of original IME Appt: SSN: Date of Injury / / / / / / Follow-up Appt. Date (if known): (Please notify the Division of any new or rescheduled appt. date) 3. MMI/Impairment Information Name of treating physician: New MMI Date (as provided by the treating physician): New Impairment Rating (as provided by treating physician): 4. The Respondent in this case wishes to request a follow-up IME: Respondent Representative Name: Address: / Date / 5. CERTIFICATE OF MAILING: A copy of this document was placed in the U.S. Mail or delivered to the following parties this __________ day of ______________________, 20________. List the names and address of all persons copied: Claimant: Claimant's Attorney: Division of Workers' Compensation, IME Unit, 633-17th Street, Suite 400, Denver, CO 80202 Fax: 303.318.8659 By: Signature If you have questions about the IME process, contact the Division of Workers' Compensation IME Unit: 303.318.8655. WC178 Rev 01/06 American LegalNet, Inc. www.USCourtForms.com
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