Form WC180 "Division Ime Physician Summary Disclosure Form (Claimant)" - Colorado

What Is Form WC180?

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 June 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 WC180 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 WC180 "Division Ime Physician Summary Disclosure Form (Claimant)" - Colorado

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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
Clear Entire Form
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