Notice Of Agreement To Limit The Scope of DIME {WC200} | Pdf Fpdf Docx | Colorado

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Notice Of Agreement To Limit The Scope of DIME {WC200} | Pdf Fpdf Docx | Colorado

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

This is a Colorado form that can be used for Workers Comp.

Alternate TextLast updated: 3/5/2019

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en-USCOLORADO DEPARTMENT OF LABOR AND EMPLOYMENT Notice of Agreement to Limit the Scope of the Division Independent Medical Examination (DIME) en-USRequesting Party: Claimant Carrieren-USWC #: þ þ Claimant Name: þ en-USBoth parties hereby notifying the DIME Physician to en-USLIMIT THE SCOPE OF THE DIMEen-US on the following en-US en-USissues: Maximum Medical Improvement Permanent Impairment þ Apportionment en-USen-US en-USPhysician:en-USWe hereby certify that the above statements are true and correct to the best of ouren-US en-USknowledge. Requesting Party Signature þ Date Non-Requesting Party Signature þ Date en-USCERTIFICATE OF MAILINGpackage served to the DIME Physician, next to the dated cover sheet and the chronological index. The parties American LegalNet, Inc. www.FormsWorkFlow.com

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