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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. 2. 3. Claimant Name DIME Physician Is the claimant at MMI for this injury? Yes, the claimant reached MMI on (date) WC # Date of Injury Appointment Date Report Due Date No, the claimant is not at MMI Whole person impairment % WP 4. Physician's Rating (Unapportioned Ratings) Spine Extremity Impairment Left upper extremity Right upper extremity Left lower extremity Right lower extremity Psychological Other % Final Combined Unapportioned Impairment Rating No prior injury, no apportionment Was the current date of injury before July 1, 2008? No, after July 1,2008 Was the previous condition work-related? No, not work-related Was the previous condition independently disabling? Yes No, not independently disabling No apportionment can be done. Use Combined Unapportioned rating (from Section 4 above) Yes Yes % UE Convert to WP % UE Convert to WP % LE Convert to WP % LE Convert to WP % WP % WP % WP % WP % WP % WP % WP 5. To Determine Apportionment, Answer the Following Based On Prior Medical Records or Objective Findings: Current Rating After Apportionment A P P O R T I O N Spine Left upper extremity Right upper extremity Left lower extremity Right lower extremity Psychological Other Final Combined/Apportioned Rating % UE % UE % LE % LE % WP % WP % WP % WP % WP % WP % WP % WP 6. Signature Date REMEMBER TO ADDRESS ALL ISSUES ON THE DIME APPLICATION This form, your narrative report, and applicable worksheets must be completed. Send the original report 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. 6/16 American LegalNet, Inc. www.FormsWorkFlow.com
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