Get Co Cdle Wc77 2018-2025

The CO CDLE WC77 form is essential for requesting a Division Independent Medical Examination (DIME) in Colorado. This guide will provide clear steps to help you complete the form effectively and accurately.

Follow the steps to complete the CO CDLE WC77 form online.

1. Press the ‘Get Form’ button to access the form and open it in your document editor.
2. In the first section, identify the requesting party. Select 'Claimant' and provide the necessary details, including the WC number and date of injury. Indicate if an interpreter is needed and fill in the claimant's contact information, including name, phone number, email, and address.
3. If applicable, provide details for the claimant’s attorney, including their contact information. This section must be completed if the claimant has legal representation.
4. Fill in the carrier information, including their phone number and adjuster details, as well as the contact information for the carrier's attorney if one is involved.
5. Propose accredited physicians for the DIME. Ensure that the selected physicians are Level II accredited. You should be able to find a list of accredited physicians in the resources provided.
6. Acknowledge the payment responsibilities for the DIME. If payment cannot be managed, consider the Application for Indigent Determination and be aware of the deadlines for submitting these forms.
7. Complete the application section by specifying the medical reasons for the DIME and checking the relevant regions and body parts that the physician will evaluate.
8. Document the medical provider history, ensuring you list all physicians who have treated the claimant for relevant conditions and include their addresses and any MMI dates.
9. Select the applicable payment option for the DIME based on the timeline since the injury and the number of body regions involved.
10. Finally, complete the certificate of mailing, ensuring that copies of the completed document are sent to proper parties, including the Division of Workers’ Compensation.
11. Review all entered information for accuracy. Once complete, you can save your changes, download the document, print it, or share it as necessary.

Complete your CO CDLE WC77 document online today to ensure your DIME request is processed promptly.