COLORADO DEPARTMENT OF LABOR & EMPLOYMENT DIVISION OF WORKERS' COMPENSATION APPLICATION FOR "24 MONTH" DIVISION INDEPENDENT MEDICAL EXAMINATION (IME) REQUESTED PURSUANT TO C.R.S. 8-42-107(8)(b)(II)(A)-(D) This form must be submitted to the Division and all parties by the requesting party when the statutory conditions for requesting a "24-Month" independent medical examination have been met. If the requester wishes to cancel the IME process, notify the IME Section of the Division in writing. IME INFORMATION 1. 2. Check the box for the party requesting the IME: WC# Claimant Name 3. 4. 5. 6. 7. *Claimant's Attorney Carrier Name Adjuster Name Carrier's Attorney If Agreed Upon IME Physician Physician Address IME Appointment Date 8. If Unable to Agree Upon IME Physician Preferred Location 9. 1st Choice 2nd Choice Appointment Time Phone Number ( ) Phone Number Phone Number ( ( ) ) Carrier Claim # Date of Injury Claimant Carrier Social Security # Phone Number Phone Number ( ( ) ) List specific part(s) of the body and all conditions to be evaluated, including psychiatric where appropriate. 10. 11. The physician shall consider the following issues if relevant: Maximum medical improvement, permanent impairment, and apportionment. List any concerns to be addressed by the IME Physician (for example, further need for surgery). *If the claimant and/or insurer is/are represented by an attorney, all Division correspondence will be mailed only to the attorney(s) listed. WC78 Rev. 06/13 Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com 12. MEDICAL PROVIDER HISTORY List name AND address of each physician who has evaluated or treated the claimant for this and/or any other relevant medical condition or injury. If a physician assigned an MMI date or an impairment rating, list the information. At least one MMI date must be listed for this "24 Month" IME to proceed. Attach additional pages, if needed. The Division and the IME physician use this information to assure there is no conflict of interest. Physician Name Physician Address (Street Address, City, State and Zip Code) MMI Date % Rating if any (WP or Extremity) 13. CERTIFICATE OF PAYMENT FOR IME I hereby certify that I will be responsible for payment of the Division of Workers' Compensation Independent Medical Exam. I understand that this payment MUST be made to the selected physician's office at least ten (10) calendar days before the scheduled exam. **Check Here_____ if the claimant is the requester and has received a determination of indigence by order of an administrative law judge, or if an indigence proceeding is pending. If there has been an order granting indigence the insurance carrier or employer must advance the funds to pay for this IME, regardless of whether the claimant signs below. It is requested that a copy of the judge's order be attached to this application. By: Requester's Signature Requester's Name Requester's Address 14. CERTIFICATE OF MAILING: Copies of this document were placed in the U.S. mail or delivered to the following parties this day of Name , Address . List the names and addresses of all persons copied: Claimant: Claimant's Attorney: Carrier: Carrier's Attorney: Division of Workers' Compensation, 633 17th St., Suite 400, Denver, CO 80202-3660 (Send original document to the Division.) By: Signature If you have any questions about the IME process, contact the Division of Workers' Compensation IME Unit. Division of Workers' Compensation ­ IME Unit 633 17th St., Suite 400 Denver, CO 80202-3660 Phone: 303.318.8655 / Toll Free: 888.390.7936 WC78 Rev. 06/13 Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com