Authorized treating physician's initial, progress and closing report: diagnosis, work status/restrictions, treatment plan, MMI date and permanent impairment.
- Completed by
- Authorized treating physician (ATP)
- Format
- Language
- English
Colorado workers' comp forms for ATPs and DIME physicians
The Physician's Report (WC164), prior authorization and guideline notices, impairment rating worksheets and the Division IME forms, with who completes each one.
Colorado's Division of Workers' Compensation (DOWC) expects the authorized treating physician (ATP) to file the Physician's Report of Workers' Compensation Injury (WC164) at the first visit, whenever restrictions change and at maximum medical improvement (MMI). The Authorized Treating Provider's Request for Prior Authorization (WC188) asks the insurer to approve treatment, especially treatment outside the Medical Treatment Guidelines. For treatment the provider certifies is consistent with the guidelines, the Notification by an Authorized Treating Provider (WC195) goes to the insurer instead.
The WC164 goes to the insurer, with a copy to the injured worker. Permanent impairment is rated by a Level II accredited physician, either the ATP or a Division IME (DIME) physician, on spine, upper and lower extremity, hearing, vision and mental impairment (WCM3) worksheets attached to the rating report. DIME physicians also file the WC132 summary sheet and, on request, complete the WC179 disclosure online. Therapists and chiropractors report rehabilitation progress on the Rehabilitation Communication Form (WC196).
Physicians, NPs and PAs
Requests insurer prior authorization for treatment, especially treatment outside the Medical Treatment Guidelines.
- Completed by
- Authorized treating provider
- Format
- Language
- English
Notifies the insurer of prescribed treatment that the provider certifies is consistent with the Medical Treatment Guidelines (so it may proceed without prior authorization unless contested).
- Completed by
- Authorized treating provider
- Format
- Language
- English
Worksheets for rating lower extremity impairment (Part 1: toes, optional; Part 2: hip, knee and ankle).
- Completed by
- Level II accredited physician performing the impairment rating (ATP or DIME)
- Format
- Language
- English
Summarizes specific-disorder and range-of-motion spine impairment (with optional apportionment) for the final spine rating.
- Completed by
- Level II accredited physician performing the impairment rating (ATP or DIME)
- Format
- Language
- English
Worksheets for rating upper extremity impairment (Part 1: digits; Part 2: shoulder, elbow and wrist) under the AMA Guides 3rd ed. (revised) as adopted in Colorado.
- Completed by
- Level II accredited physician performing the impairment rating (ATP or DIME)
- Format
- Language
- English
Discloses ownership interests and employment relationships of an employer-designated health care provider on request.
- Completed by
- Designated health care provider (clinic/physician)
- Format
- Language
- English
Division IME examiner's one-page summary of findings on MMI date and impairment ratings.
- Completed by
- Division IME physician
- Format
- Language
- English
DIME physician's disclosure of business, financial, employment or advisory relationships with the insurer/self-insured employer, provided on a party's request.
- Completed by
- Division IME physician
- Format
- Online only
- Language
- English
Worksheet for assigning a permanent mental/behavioral impairment rating under Colorado rules.
- Completed by
- Level II accredited physician (psychiatrist or other rating physician)
- Format
- Language
- English
Chiropractic
Therapist's structured progress note on improvement, compliance, objective measurements and functional scoring for the treating physician and insurer.
- Completed by
- Physical or occupational therapist / chiropractor providing rehabilitation
- Format
- Language
- English
Hearing
Worksheet for computing binaural hearing impairment for a permanent impairment rating.
- Completed by
- Level II accredited physician performing the impairment rating (ATP or DIME) with audiometry
- Format
- Language
- English
Vision
Worksheet for computing visual system impairment for a permanent impairment rating.
- Completed by
- Level II accredited physician performing the impairment rating (ATP or DIME) with eye examination
- Format
- Language
- English
Required structure for the Division IME physician's report on maximum medical improvement and permanent impairment.
- Completed by
- Division IME physician (Level II accredited)
- Format
- Language
- English
More US forms
How this list is checked
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
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Frequently asked questions
When do I complete the WC164?
At the initial visit, whenever work restrictions change, and at maximum medical improvement as the closing report. The authorized treating physician completes both pages: diagnosis, work status and restrictions, treatment plan, MMI date and any permanent impairment. Send it to the insurer and give a copy to the injured worker.
What is the difference between the WC188 and the WC195?
The WC195 notifies the insurer of treatment the authorized treating provider certifies is consistent with the Medical Treatment Guidelines, so it may proceed without prior authorization unless contested. The WC188 requests prior authorization, especially for treatment outside the guidelines, and the insurer must respond within the Rule 16 deadline. Both go to the insurer or its agent.
Who can complete Colorado impairment rating worksheets?
A Level II accredited physician performing the rating, either the authorized treating physician or a Division IME physician. Worksheets cover the spine (Figure 84), upper extremity, lower extremity, hearing (with audiometry) and vision, and the WCM3 covers permanent mental impairment. Upper extremity ratings follow the AMA Guides 3rd edition (revised) as adopted in Colorado. Each worksheet is attached to the impairment rating report.
Which forms does a DIME physician file?
The Division IME physician writes the report on the DIME Report Template (WC201) and sends it to the Division, the claimant and the insurer. The one-page DIME Examiner's Summary Sheet (WC132) is filed with the Division along with the report. When a party asks, the physician completes the DIME Physician Summary Disclosure (WC179), an online form covering relationships with the insurer or self-insured employer.