WC # Claimant NameDIME PhysicianIs the claimant at MMI for this injury? Date of Injury Appointment Date Report Due Date Ye s, the claimant reached MMI on (date) No, the claimant is not at MMI 4.DIME Physician222s Rating (Unapportioned Ratings) Spine % WP Extremities Right upper extremity % WP Left upper extremity % WP Right lower extremity % WP Left lower extremity % UE Convert to WP % UE Convert to WP % Convert to % Convert to WP % WP Psychological % WP Other % % WP Final Combined Unapportioned Impairment Rating % WP Final Combined Apportioned Impairment Rating (*Desk Aid #14, Apportionment Calculation Worksheet must be attached) *% WP 5.SignatureDate REMEMBER TO ADDRESS ALL ISSUES ON THE DIME APPLICATION This form, your narrative report, and applicable worksheets must be completed. Send the report to the Division with copies to both parties (or their attorneys) within 20 calendar days from the appointment date. American LegalNet, Inc. www.FormsWorkFlow.com Issued October 2008 APPORTIONMENT OF IMPAIRMENT Guideline for Accredited Physicians 226 Injuries pre-and post- 7/1/2008 Changes per Senate Bill 08-241 and Workers222 Compensation Rule 12-3 MEDICAL RECORDS OR OTHER OBJECTIVE EVIDENCE SUBSTANTIATES PRE-EXISTING IMPAIRMENT (1)221Disabled222 requires information that the prior injury was identified, treated, and independently disabling at the time of the currentinjury. 221Disability222 is expected to include conditions which adversely impact the claimant222s ability to perform his job, or limits theclaimant222s access to other jobs. Permanent work restrictions would generally fall in this category. Previous Work-related injury Previous Non-work- related injury identified & treated Patient was disabled prior to and at time of current injury (1) Patient not disabled Calculate impairment for this work-related injury (no apportionment) Current Injury After July 1, 2008 Current Injury Before July 1, 2008 Deduct past impairment from current total Apportioned rating Calculate and clearly state current total impairment rating including past impairment American LegalNet, Inc. www.FormsWorkFlow.com