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Colorado WC179: DIME Physician Summary Disclosure

On a party's request, a Colorado Division IME panel physician must list business, financial, employment and advisory relationships between the physician (or affiliated entities) and the insurer or self-insured employer in the case, under C.R.S. 8-42-107.2(3.5)(a) and Rule 11-3. WC179 is the one-page form for that disclosure, with a checkbox to attest there is nothing to disclose.

Who completes it

The DIME panel physician completes the whole form: name, any relationships, or the no-relationships attestation, then signs and dates it electronically.

Submitting and payment

How to submit it
There is no PDF to download: the physician completes and signs it online through the Adobe Sign web form linked from the DOWC forms page and the DIME Physicians page.
Who pays
The form has no fee or billing field.

Good to know

  • Physician name, signature and date are the required fields; relationships go in the lined space, or the physician checks the attestation box instead.
  • Disclosure covers relationships the physician or affiliated entities have with insurers or self-insured employers involved in the case.
  • DIME physicians should not communicate with either party except for administrative needs such as scheduling, physician selection or payment discrepancies.
  • The form footer reads WC179 Rev 10/24; it is a single page titled DIME Physician Summary Disclosure Form.

Get the official form

Download the current version from the source each time; forms change without notice.

DIME Physician Summary Disclosure

Official page

Get the note ready with Vero

This form is completed online with Colorado Department of Labor and Employment, Division of Workers' Compensation (DOWC), so there is no PDF to fill. Vero Scribe writes the visit note it draws on, so the details are ready when you complete it.

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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.

Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.

Frequently asked questions

How do I submit Colorado WC179?

Online only. The Division links an Adobe Sign web form titled WC179 Summary Disclosure Form from its forms page and from the DIME Physicians page, where it is labeled Submit the Physician Summary Disclosure Form Online. The physician types the information and signs electronically.

What if a DIME physician has no relationships to disclose?

Check the box attesting that there are no relationships to disclose under C.R.S. 8-42-107.2(3.5)(a) and Rule 11-3, then complete the name, signature and date. The lined space is used only when there are business, financial, employment or advisory relationships to list.

When is a WC179 disclosure required?

When a party in the case asks for it. A physician on the Division IME panel must then list relationships with the insurer or self-insured employer involved, under C.R.S. 8-42-107.2(3.5)(a) and Workers' Compensation Rule of Procedure 11-3.