Form Wc178 Request/notification For Follow-Up Ime
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1COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT
DIVISION OF WORKERS’ COMPENSATION
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INDEPENDENT MEDICAL EXAMINATION PROGRAM
REQUEST/NOTIFICATION FOR FOLLOW-UP IME
Instructions: This form must be submitted when the claimant previously had a Division IME and was determined to
be ‘not at MMI,’ and the insurer/respondent is now requesting a follow-up IME. Per Rule 11, to the extent possible
the follow-up IME will be held with the original IME physician. If the original physician is unable to perform the
follow-up, please notify the Division’s IME Unit. The requesting party is responsible for payment, and also “shall
pay any additional examination expense” as set forth in the Rule. If this follow-up is on a reopened claim, the facts
of the specific case may determine the party responsible for requesting and paying for the exam. Do not submit this
form if the follow-up is for repeat range of motion only; please notify the Division of the date and time of the
appointment.
WC#
Date of original IME Appt:
/
/
1. Claimant Name
SSN:
Date of Injury
/
/
2. IME Physician
Follow-up Appt. Date (if known):
/
/
(Please notify the Division of any new or rescheduled appt. date)
3. MMI/Impairment Information
Name of treating physician:
New MMI Date (as provided by the treating physician):
/
/
Date
New Impairment Rating (as provided by treating physician):
4. The Respondent in this case wishes to request a follow-up IME:
Respondent Representative Name:
Address:
5. CERTIFICATE OF MAILING: A copy of this document was placed in the U.S. Mail or delivered to the
following parties this __________ day of ______________________, 20________.
List the names and address of all persons copied:
Claimant:
Claimant’s Attorney:
th
Division of Workers’ Compensation, IME Unit, 633-17
Street, Suite 400, Denver, CO 80202 Fax: 303.318.8659
By:
Signature
If you have questions about the IME process, contact the Division of Workers’ Compensation IME Unit: 303.318.8655.
WC178 Rev 01/06
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