Notice Of Agreement To Limit The Scope of DIME {WC200}

WC200 - NOTICE OF AGREEMENT TO LIMIT THE SCOPE OF THE DIVISION INDEPENDENT MEDICAL EXAMINATION (DIME). This form is used by the Colorado Department of Labor and Employment, Division of Workers’ Compensation, to document an agreement between the claimant and the insurer to limit the issues that the DIME physician will evaluate. This form allows the parties to indicate whether the DIME should address specific matters such as Maximum Medical Improvement (MMI), Permanent Impairment, or Apportionment. It also provides space to list any specific body parts or conditions that should not be considered by the DIME physician. Both the requesting and non-requesting parties must sign the form to confirm their mutual agreement. Additionally, the form includes a Certificate of Service section to confirm that copies have been sent to the Division, the claimant or their attorney, the insurer or their attorney, and the DIME physician. www.FormsWorkFlow.com