Form WC76 "Request for Appointment to the Division Independent Medical Examination Panel (Dime)" - Colorado

What Is Form WC76?

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 October 1, 2018;
  • 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 WC76 by clicking the link below or browse more documents and templates provided by the Colorado Department of Labor and Employment.

ADVERTISEMENT
ADVERTISEMENT

Download Form WC76 "Request for Appointment to the Division Independent Medical Examination Panel (Dime)" - Colorado

Download PDF

Fill PDF online

Rate (4.5 / 5) 12 votes
Clear Entire Form
COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT
DIVISION OF WORKERS' COMPENSATION
633 17th St., Suite 400, Denver, CO 80202-3626
303.318.8655
Request for Appointment to the
Division Independent Medical Examination Panel (DIME)
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?
Yes
No
If yes, Level II Accreditation is necessary.
Have you had more than 384 hours of direct patient care (excluding medical/legal evaluation) as part of your practice
within the last calendar year OR engaged in at least 384 hours of direct patient care (excluding medical/legal
evaluation) during the previous five years and demonstrated additional competency in the field of disability evaluation
through certification by the American Board of Independent Medical Examiners, the International Academy of
Independent Medical Evaluators, or equivalent continuing medical education courses?
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 DIME Unit and withdraw from the DIME panel should any restrictions be imposed.
No
Yes
WC076 Rev 10/18
Page 1 of 2
Clear Entire Form
COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT
DIVISION OF WORKERS' COMPENSATION
633 17th St., Suite 400, Denver, CO 80202-3626
303.318.8655
Request for Appointment to the
Division Independent Medical Examination Panel (DIME)
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?
Yes
No
If yes, Level II Accreditation is necessary.
Have you had more than 384 hours of direct patient care (excluding medical/legal evaluation) as part of your practice
within the last calendar year OR engaged in at least 384 hours of direct patient care (excluding medical/legal
evaluation) during the previous five years and demonstrated additional competency in the field of disability evaluation
through certification by the American Board of Independent Medical Examiners, the International Academy of
Independent Medical Evaluators, or equivalent continuing medical education courses?
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 DIME Unit and withdraw from the DIME panel should any restrictions be imposed.
No
Yes
WC076 Rev 10/18
Page 1 of 2
CERTIFICATION
I request approval as an independent medical examiner.
I will provide independent and
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
conduct a Division Independent Medical Examination between 45 and 75 calendar days from request.
I agree to submit a report to the Division and both parties as marked on the DIME Application within 20
This report will include the DIME
calendar days of the examination of the claimant.
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 Division Independent Medical
Examination 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 ________________________, _____________.
________________________________________
SEAL
Notary Public
Address:
My Commission Expires: ___________________
WC076 Rev 10/18
Page 2 of 2
Page of 2