Designated Health Care Provider Disclosure Form {WC30}

COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT DIVISION OF WORKERS' COMPENSATION Designated Health Care Provider Disclosure Form Provider name: Provider address: Instructions: Pursuant to §8-43-404 (5)(a)(I)(A) and Workers' Compensation Rule of Procedure 8-3, upon request of an interested party, a designated provider shall provide a list of ownership interests and employment relationships to the requesting party within 5 days of such request. The information in this form must be updated when there is a change so that it is current to within 30 days of the date of the request. Additional pages may be used if necessary. I. I have an ownership interest in the following business or entities: ("Ownership interest" means ownership in a business or entity that is involved in providing medical care and through which the physician can exercise direction and control.) II. I have employment relationships or perform medical services for the following interests: (Employment relationships include any and all relationships in which the undersigned is in an employer/employee relationship to perform medical services in exchange for remuneration.) Signed: Dated: WC 30 11/07 Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com CERTIFICATE OF MAILING: Copies of this document were placed in the U.S. mail or delivered to the following parties this day of , . Day Month Year List the names and addresses of all persons copied: By: Signature WC 30 11/07 Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com