Division IME Physician Summary Disclosure Form (Insurer Or Self-Insured Employer) {WC179}

COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT DIVISION OF WORKERS' COMPENSATION Division IME Physician Summary Disclosure Form (Insurer or Self-Insured Employer) Physician name: Physician address: Instructions: Pursuant to C.R.S. 8-42-107.2(3.5)(a) and Workers' Compensation Rule of Procedure 11-3, upon request of a party a physician on the Division IME panel shall provide a list of business, financial, employment, or advisory relationship between the listed physician and the insurer or self-insured employer involved in a case. This disclosure shall be provided to the Division IME Unit within 7 business days of the notice of such request. Alternatively, a completed form may be pre-submitted to the Division IME Unit. If such form is pre-submitted, the information in this form must be updated within 30 days of a material change in a relationship or once per year. Additional pages may be used if necessary. I. Summarize any business, financial, employment or advisory relationships you or your affiliated entities have with insurers or self-insured employers, or alternatively supply summary information on any business, financial, employment or advisory relationship you may have with the insurer/selfinsured employer in an identified workers' compensation case. Signed: WC 179 06/10 Dated: American LegalNet, Inc. www.FormsWorkFlow.com