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Division IME Examiners Summary Sheet WC132 - Colorado

Division IME Examiners Summary Sheet Form. This is a Colorado form and can be used in Workers Comp .
 Fillable pdf Last Modified 5/17/2012
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COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT DIVISION OF WORKERS' COMPENSATION INDEPENDENT MEDICAL EXAMINATION PROGRAM DIVISION IME EXAMINER'S SUMMARY SHEET 1. Claimant Name 2. DIME Physician 3. MMI Information Yes, the claimant reached MMI on Date WC# Appointment Date Report Due Date 4. Date of Injury Previous Physician's Rating No, the claimant is not at MMI 5. DIME Physician's Rating (Use all appropriate spaces) Unapportioned Extremity Ratings: Right upper extremity Converted to whole person Right lower extremity Converted to whole person Unapportioned Whole Person Ratings: % WP extremity % WP other physical (digestive, visual, etc.) Final/combined % WP psychological % WP additional physical (spinal) % in WP (UNAPPORTIONED) % WP % WP Left upper extremity Converted to whole person % in WP Left lower extremity Converted to whole person % in WP % WP % WP Combined upper right & left extremity Combined lower right & left extremity 6. Apportionment Information-REVIEW THE INSTRUCTIONS ON THE BACK OF THIS FORM. REMEMBER TO DISCUSS YOUR APPORTIONMENT IN YOUR NARRATIVE REPORT. No, Apportionment is not applicable (skip to #7) Yes, Apportionment is applicable CHECK whether the prior impairment is: Work-related Non-work-related IME Physician's Final Rating After Apportionment: Right upper extremity Right lower extremity % WP extremity % WP other physical (digestive, visual, etc.) Final/combined 7. Signature % UE % LE % WP % WP Left upper extremity Left lower extremity % UE % LE % WP % WP % WP psychological % WP additional physical (spinal) % in WP (APPORTIONED) Date REMEMBER TO ADDRESS ALL ISSUES ON THE APPLICATION FOR DIVISION IME FORM. This form, your narrative report, and applicable worksheets must be completed for every IME and the original sent to the Division with copies to both parties (or their attorneys) within 20 calendar days from the appointment date. Division of Workers' Compensation - IME Unit 633 17th Street, Suite 400, Denver, CO 80202 Telephone # (303) 318-8655 Fax # (303) 318-8659 WC132 Rev 03/12 Page 1 of 3 American LegalNet, Inc. www.FormsWorkFlow.com As a DIME physician, you are being asked to provide a medical opinion on impairment, which may include apportionment. This summary sheet allows you to provide relevant medical information that may be used by the parties to pursue the claim. When the current date of injury is prior to July 1, 2008, the physician shall apportion any preexisting workrelated or non-work-related medical impairment from a current work-related injury or occupational disease, where medical records or other objective evidence substantiate a preexisting impairment to the same body part. (See Rule 12-3(A)) If there is insufficient information to measure the change accurately, the physician shall not apportion. ************** When the current injury occurred on or after July 1, 2008: If the prior injury is work-related: Apportion when sufficient records are available that reflect the patient's prior impairment to the same body part(s) or for the same condition. If the records reflect the prior impairment rating as a percentage, deduct the prior assigned percentage from the current rating. If a specific prior percentage is not available, assess the prior injury or condition for an impairment rating and deduct it from the current rating. If there is insufficient information to identify or determine the prior impairment, do not apportion. Due to the July 1, 2008 change in the law, the final impairment rating that is used by the parties to conclude the workers' compensation case may be different from your findings. This does not imply that your findings were incorrect. If the prior injury is non work-related, all three of the following must apply in order to apportion: (1) Sufficient medical information is available which establishes that a prior injury to the same body part has been identified and treated; (2) The prior injury meets the criteria for a permanent impairment; (3) That prior impairment was independently disabling at the time of the current injury. FURTHER, if there is insufficient information to identify or determine the prior impairment, do not apportion. See Rule 12-3(B) for details. **REMEMBER TO DISCUSS THE BASIS OF YOUR APPORTIONMENT IN YOUR NARRATIVE REPORT. ** ______________________________________________________________________________ Current Injury After July 1, 2008 Previous Non-workrelated injury identified & treated Previous Work-related injury Patient not disabled (1) Patient was disabled prior to and at time of current injury (1) Identify, calculate and clearly state current total impairment rating including past impairment Calculate impairment for this work-related injury (no apportionment) (1) `Disabled' requires information that the prior injury was identified, treated, and independently disabling at the time of the current injury. `Disability' is expected to include conditions which adversely impact the claimant's ability to perform his job, or limits the claimant's access to other jobs. Permanent work restrictions would generally fall in this category. Deduct past impairment from current total Apportioned rating WC132 Rev. 03/12 Page 2 of 3 American LegalNet, Inc. www.FormsWorkFlow.com WC#______________________ REMINDER Your narrative report, and applicable worksheets must be completed for every IME and the original sent to the Division with copies to both parties (or their attorneys) within 20 calendar days from the appointment date. Please complete the Certificate of Mailing/Service below and include this page with your narrative report, and send to all parties. For your convenience below are the addresses of the parties: Claimant or Claimant's Attorney: Carrier or Carrier's Attorney: Original Copy To: Division of Workers' Compensation Independent Medical Exam Unit 633 17th Street, Suite 400 Denver, CO 80202 CERTIFICATE OF SERVICE/MAILING: Copies of this document were placed in the U.S. mail or delivered to the above parties this __________ day of ______________________, ____________ By: _________________________________________ Signature WC132 Rev. 03/12 Page 3 of 3 American LegalNet, Inc. www.FormsWorkFlow.com
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