Division IME Physician Summary Disclosure Form (Claimant)
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Division IME Physician Summary Disclosure Form (Claimant) Form. This is a Colorado form and can be use in Workers Comp.
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COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT
DIVISION OF WORKERS’ COMPENSATION
Division IME Physician Summary Disclosure Form (Claimant)
WC#:
Name of Claimant:
Claimant address:
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 an interested party a physician on the Division IME panel shall provide to
the Division IME Unit a list of business, financial, employment, and/or advisory relationships
between a listed physician and the claimant who is a party to the claim. This summary
disclosure shall be provided to the Division within 7 business days of the date of the notice of
such request.
I. I or my affiliated entities have the following business, financial,
employment or advisory relationship with the above-named claimant:
Signed:
Dated:
WC 180 6/2010
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