Form WC146 "Notice and Proposal to Select an Independent Medical Examiner" - Colorado

What Is Form WC146?

This is a legal form that was released by the Colorado Department of Labor and Employment - a government authority operating within Colorado. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on July 1, 2010;
  • The latest edition provided by the Colorado Department of Labor and Employment;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form WC146 by clicking the link below or browse more documents and templates provided by the Colorado Department of Labor and Employment.

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Download Form WC146 "Notice and Proposal to Select an Independent Medical Examiner" - Colorado

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Go to Form
Instructions for Completing the
Notice and Proposal to Select an
Independent Medical Examiner
Please read all pages
This form is “fillable.” That means you can type the information onto
the form from your computer and print the form. You will not be able
to save the form onto your computer’s hard drive.
When you open the form, click in the “WC#” box (field), complete the
information, and use the tab key to navigate to the next field. Do not
use the Enter key; pressing the Enter key will only page down. Each
field has been limited. This means that you cannot continue to type
information into a field if it doesn’t fit into the space provided.
Use numbers only to fill in the fields for Social Security #. Do not use
dashes or parentheses; when you tab out of the field, it will fill in
automatically. To fill in a
check
box, click inside the box with your
mouse. The “Certificate of Mailing” fields are surrounded by a
gray
border. Type the information in the first field and tab to the next to
enter more information.
To clear or delete all the information you have typed onto the form,
click on the red
“Clear Entire
Form” button. To change the information
in one field, use the backspace or delete key.
1
Go to Form
Instructions for Completing the
Notice and Proposal to Select an
Independent Medical Examiner
Please read all pages
This form is “fillable.” That means you can type the information onto
the form from your computer and print the form. You will not be able
to save the form onto your computer’s hard drive.
When you open the form, click in the “WC#” box (field), complete the
information, and use the tab key to navigate to the next field. Do not
use the Enter key; pressing the Enter key will only page down. Each
field has been limited. This means that you cannot continue to type
information into a field if it doesn’t fit into the space provided.
Use numbers only to fill in the fields for Social Security #. Do not use
dashes or parentheses; when you tab out of the field, it will fill in
automatically. To fill in a
check
box, click inside the box with your
mouse. The “Certificate of Mailing” fields are surrounded by a
gray
border. Type the information in the first field and tab to the next to
enter more information.
To clear or delete all the information you have typed onto the form,
click on the red
“Clear Entire
Form” button. To change the information
in one field, use the backspace or delete key.
1
“Clear Entire
Form” button
Clears all information at once
“Check
Box”
Click in Box
2
“Gray
Border”
Enter Information and tab to next field
3
COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT
DIVISION OF WORKERS’ COMPENSATION
Clear Entire Form
NOTICE AND PROPOSAL TO SELECT AN INDEPENDENT MEDICAL EXAMINER
Back to Instructions
Complete Sections I and II. Please read the information at the bottom of this form
SECTION I Notice and Proposal of Independent Medical Examiner
WC #
Carrier Claim #
Social Security #
Claimant Name
Date of Injury
I , the (check one) . □ claimant
□ respondent,
disagree with the determination by Dr.
, dated
, and I request a Division IME. I understand that the Division IME will consider the issues of MMI,
permanent impairment and apportionment, if relevant.
I propose any one of the following physicians to conduct the IME: (The physician must be Level II accredited.) A list of accredited
physicians, as well as other information and forms, is available on the Division’s web site. You may also call the Customer Service Unit
listed below.
I understand that I need to talk to the other party to discuss this request. Once the negotiation process is completed, I must
submit the Application for IME form to the Division and all parties.
Signature of Requester
Phone #
*Check here if you claim to be unable to pay [indigent] the cost of the IME. See Instruction No. 7, below.
SECTION II Certificate of Mailing
Copies of this document were placed in the U.S. mail or delivered to the following parties this
,
day of
List the names and address of all persons copied:
Name
Address
Claimant:
Claimant’s Attorney:
Carrier:
Carrier’s Attorney:
th.
Division of Workers’ Compensation, 633 17
St., Suite 400, Denver, CO 80202-3626
By:
Signature
INFORMATIONAL SUMMARY
The following is a brief outline of the Division Independent Medical Examination (IME) process. This general information may not include all
circumstances and is not meant as legal advice. Also refer to Rule 11. If you have any questions, contact the Customer Service Unit listed below.
1.
The party requesting the IME (requester) must complete the Notice and Proposal for Independent Medical Examiner form. The requester must send
this Notice to the other party. If you are the claimant, the other party is the insurance carrier. If you are the Insurance Carrier, the other party is the
claimant or claimant’s representative, if applicable.
2.
The parties have 30 calendar days to negotiate the selection of the Independent Medical Examiner (physician who will conduct the IME). The
requester needs to obtain an Application for Independent Medical Examination (IME), Form WC77, during this time.
3.
If the parties agree on the Independent Medical Examiner, the requester must schedule the examination promptly with the physician. The requester
must also complete the Application for IME form and submit this to the Division of Workers’ Compensation, the physician, and the other party.
4.
If the parties do not agree on the Independent Medical Examiner, or there is no response to the Notice and Proposal, the insurance carrier must
complete the Notice of Failed IME Negotiation, Form WC165. A copy must be sent to the Division and the claimant.
a.
The party requesting the IME shall have 30 days from the date of the failure to agree or respond to submit an Application for Independent
Medical Examination (IME), Form WC77. Within 10 calendar days of receiving the Application, the Division will designate a panel of three
qualified physicians from which the parties must select one physician pursuant to procedures stated in Rule 11-3. The parties will be notified in
writing of the three-physician panel.
b.
The form which provides the three-physician panel will contain additional instructions on how and when to strike a doctor from the list, and
other options such as requesting from the physicians information regarding their business and financial interests. This may assist the parties in
deciding which physician to strike from the list.
c.
If the parties do not complete this process in 15 business days, the Division will select one name and notify the parties. Within 5 business days
of the physician selection, the requesting party must telephone the physician and schedule the examination.
5.
The carrier must submit medical records to the physician and other party at least 14 calendar days before the examination.
6.
The claimant must notify the carrier if a language interpreter is needed at least 14 calendar days before the examination. The requester is
responsible for paying the interpreter.
7.
The requester must make the payment to the IME physician at least 10 calendar days before the examination. If you wish to assert that you are
unable to pay for the IME, you must obtain and file an “Application for Indigent Determination (IME)”, Form WC35 IME, within 20 days of the
filing of this Notice and Proposal. Contact the Division Customer Service Unit or IME Unit to obtain the form or for further information.
8.
The physician is required to mail the IME report to the parties and the Division within 20 calendar days of the examination.
9.
If the requester wishes to cancel the IME process, contact the IME Section of the Division immediately.
If you have any questions, or need an Application for Independent Medical Examination (IME), Form WC77, or any other forms, contact the
Division of Workers’ Compensation Customer Service Unit at 303.318.8700 or toll free at 888.390.7936
WC146 Rev. 07/10
Page 1 of 2
(The top portion may be used for mailing purpose. This side of the form is optional.)
NOTICE AND PROPOSAL TO SELECT AN INDEPENDENT MEDICAL EXAMINER
Form WC146
WC146 Rev. 07/10
Page 2 of 2
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