COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT Division of Workers’ Compensation Independent Medical Examination Section 633 17th St., Suite 400, Denver, CO 80202-3626 303.318.8655 Request for Appointment to the Independent Medical Examination Panel Date of Application: _______/________/________ Please Print or Type Personal Identification Last Name: First Name: MI: Office Address: City: Zip: State: Colorado Professional License No.: Office Phone: Fax: ( ( ) Degree: ) Specialty: If you are a medical doctor or a doctor of osteopathy, complete the following: Currently Board Certified by the American Board of Medical Specialties or the American Osteopathic Association? Yes No Date: / / Currently Board Eligible for specialty certification by the American Board of Medical Specialties or the American Osteopathic Association?: Yes No If yes, Board certified or eligible, name of Board: Documentation of Board Certification or eligibility in field of specialty must accompany this application. Do you intend to do impairment ratings? If yes, Level II Accreditation is necessary. Yes No Have you had more than 384 hours of direct patient care (excluding medical/legal) as part of your practice within the last year? Yes No I certify that as of the date of this application my Colorado medical license is active, with no limitations or restrictions. I will notify the IME unit and withdraw from the IME panel should any restrictions be imposed. Yes No Please send all applications to the attention of the IME coordinator at the above address WC76 Rev 01/06 Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com (see reverse side) CERTIFICATION I request approval as an independent medical examiner I will provide independentand objective medical . decisions in all cases that come before me. I will decline a request to conduct an independent medical examination if I have a conflict of interest for any reason. I agree to serve on the panel for a minimum of two years and to conduct an independent medical examination between 35 and 50 calendar days from request. I agree to submit a report to the Division and both parties as marked on the IME Application, according to Division guidelines, within 20 calendar day of the examination of the claimant. This report will include the s Division IME Examiners Worksheet, my written report, and the applicable AMA Guides worksheets. I understand my performance will be measured by the quality of my examination and reports, and not by whether my recommendations are perceived as favorable or unfavorable to the parties involved. I have read and understand all of Rule 11, which describes the independent medical exam program. I accept that examinations performed for the Division of Workers’ Compensation are paid according to fees set by the Division of Workers’ Compensation. ________________________________________ Signature _________________/________/______________ Date Subscribed before me this ________________ day of ________________________, _____________. ________________________________________ Notary Public SEAL Address: My Commission Expires: ___________________ WC76 Rev 01/06 Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com