Date Received:COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT DIVISION OF WORKERS222 COMPENSATIONLast Number and Street Provider222s Name Number and Street First City State Phone # City Fax # OR Email Zip Code NPI/FEIN State Zip Code Specify treatment/service(s) and billing code(s) � Dx/ICD-10 Code Supporting documentation attached Section ATP222s Signature � Date Form is incomplete(additional information requested)By (Print Name) Signature Title Date WC 195 Rev 0/19 Page 1 of 1 American LegalNet, Inc. www.FormsWorkFlow.com