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Colorado Form Center -

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Form

Description

wc001.pdf Employer's First Report of Injury Must be submitted electronically.
dk01_average_weekly_wage.pdf Average Weekly Wage Worksheet
wc002.pdf General Admission of Liability
wc003.pdf Notice of One-Time Change of Physician and Authorization for Release of Medical Information
wc004.pdf Final Admission of Liability
wc006.pdf Entry of Appearance
wc012.pdf Supplemental Report of Return to Work
wc015.pdf Worker's Claim for Compensation
wc018.pdf Dependents' Notice and Claim for Compensation
wc030.pdf Designated Health Care Provider Disclosure Form
wc034.pdf Request to Erase Medical Information from an Audio Recording
wc035.pdf Application for Indigent Determination (Hearing Transcript)
wc036.pdf Info Regarding Independent Medical Examination
wc036s.pdf Info Regarding Independent Medical Examination (Spanish)
wc037.pdf Petition to Reopen
wc043.pdf Rejection of Coverage by Corporate Officers or Members of a Limited Liability Company
wc044.pdf Exclusion of Uncompensated Public Officials
wc045.pdf Rejection of Coverage by Partners and Sole Proprietors Performing Construction Work on Construction Sites
wc049.pdf POSTER - Colorado Workers' Compensation Information
wc049sp.pdf POSTER - Colorado Workers' Compensation Information (Spanish)
wc050.pdf POSTER - Notice to Employer of Injury (11 x 14)
adjuster_lb.pdf Medical Reference Guides for Adjusters Low Back Pain
adjuster_csi.pdf Medical Reference Guides for Adjusters Cervical Spine Injury
wc050_2_page.pdf POSTER - Notice to Employer of Injury (two- 8 x 11 pages)
wc054.pdf Petition to Modify, Terminate, or Suspend Compensation
wc062.pdf Request for Lump Sum Payment
wc063.pdf Request for Offset of Liability to Subsequent Injury Fund
wc070.pdf Application for Admission to the Colorado Major Medical Insurance Fund
wc073.pdf Settlement Order
wc074.pdf Notice of Contest. Must be submitted electronically. A hard copy must be sent to the claimant and other parties.
wc076.pdf Request for Appointment to the Independent Medical Examination Panel
wc077.pdf Application for a Division Independent Medical Examination (IME)
wc035ime.pdf Application for Indigent Determination (IME)
dime.pdf Brochure:DIVISION OF WORKERS' COMPENSATION Independent Medical Examinations ("DIME") Program
wc078.pdf Application for 24 Month Division Independent Medical Examination (IME)
wc95.pdf Request For Insurer Information
wc098.pdf Monthly Summary
wc104.pdf Settlement Agreement - Represented Claimant
wc105.pdf Settlement Checklist and Routing Sheet
wc106.pdf First Report Transmittal Form
wc109.pdf Request for Certification
wc112.pdf Payroll Statement
wc113.pdf Surcharge Form
wc131.pdf Request for Utilization Review
wc132.pdf IME Examiner's Summary Sheet
wc134.pdf Request For Services
wc146.pdf Notice and Proposal to Select an Independent Medical Examiner
wc151.pdf Fatal Case - General Admission
wc153.pdf Fatal Case - Final Admission
wc164.pdf Physician's Report of Workers' Compensation Injury
wc165.pdf Notice of Failed IME Negotiation
wc168.pdf Notice of Change of Carrier or Adjusting Firm
wc169.pdf Sender's Transmission Profile
wc170.pdf Sender's Trading Partner Profile
wc171.pdf Third Party Administrator Location List
wc172.pdf Trading Partner Insurer List
wc174.pdf Worker's Claim for Compensation Transmittal
wc175.pdf EDI Sender Acceptance Form
wc178.pdf Request/Notification for Follow-up IME
wc179.pdf Division IME Physician Summary Disclosure Form
wc180.pdf Division IME Physician Summary Disclosure Form (Claimant)
wc181.pdf Medical billing Dispute Resolution Intake Form
wc188.pdf Authorized Treating Provider's Request for Prior Authorization
wc189.pdf Authorization for Release of Information
wc190.pdf Authorization for Release of Limited Information to Third Parties
wc191.pdf Voluntary Abandonment of Claim
wc192.pdf Motion to Close for Failure to Prosecute and Order to Show Cause
wcm3psy.pdf Permanent Work-Related Mental Impairment Report Work Sheet
wc197.pdf Request For Change Of Physician
wcm4.pdf Pharmacy Billing Statement
fraud_report.pdf Worker's Compensation Fraud Intake Form
Notice-1038.pdf NOTICE -Information Regarding Workers' Compensation and a Claimant's Rights
V2-3.pdf Audio Recording Request
Amended_App_Hrg.pdf Amended Application for Hearing
pleadingcase.pdf Pleading Submission
AppDisfgHrg.pdf Application for Hearing Disfigurement Only
AppExpd.pdf Application for Expedited Hearing
App1TimeChange.pdf Application for Expedited Hearing One-Time Change of Authorized Treating Physician
AppHrg.pdf Application for Hearing
CIS.pdf Case Information Sheet
Translator.pdf Code of Conduct for Interpreters
EntryofApprnc.pdf Entry of Appearance
CancelForm.pdf Hearing Cancellation
V2.pdf Hearing Confirmation
PetitiontoReview-Transcript.pdf Petition to Review and Request for Transcript
PetitiontoReview.pdf Petition to Review
wc193.pdf Request for a Disfigurement Award (Photo) WC 193
RequestSpecific.pdf Request for Specific Findings of Fact and Conclusions of Law
RsptoHrng.pdf Response to Application for Hearing
Subpoena.pdf Subpoena to Attend and Produce