Colorado Division of Workers222 CompensationProvider Education633 17th St., Suite 400Denver, Colorado 80202-3626303.318.8754PROVIDER COMPLIANCE AGREEMENTProvider222s Information (Please print):First and Last Name: þ þ Preferred Email Address: þ I certify that I will adhere to:a. The Medical Treatment Guidelines as adopted by the Director of the Division of Workers222 Compensation.b. The Utilization Standards and rules as adopted by the Director of the Division of Workers222 Compensation.c. All of the Colorado Workers222 Compensation laws as they apply to me as a health care provider in theColorado Workers222 Compensation system. Failure to abide by the Medical Treatment Guidelines, utilization standards, and rules and regulations established by the Director of the Division of Workers222 Compensation could result in revocation of my accreditation, pursuant to C.R.S. Section 8-42-101 (3.6). You must remain licensed by your Colorado Medical Board Specialty to maintain your accreditation.I understand and agree to comply with the terms listed above.Signature: Date: Please return this form to the Division of Workers222 Compensation, Provider Education Unit by email: or fax: (303)318-8659. American LegalNet, Inc. www.FormsWorkFlow.com