Designated Health Care Provider Disclosure Form
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Designated Health Care Provider Disclosure Form. This is a Colorado form and can be use in Workers Comp.
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Tags: Designated Health Care Provider Disclosure Form, WC30, Colorado Workers Comp,
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:
WC 30 11/07
Dated:
Page 1 of 2
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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
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