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Colorado WC30 Designated Provider Disclosure Form

When an interested party asks, a designated provider in a Colorado workers' compensation case must disclose its business ties. Under C.R.S. 8-43-404(5)(a)(I)(A) and Rule 8-3, the provider uses WC30 to list ownership interests in medical businesses it can direct and control, and employment relationships in which it performs medical services for pay.

Who completes it

The designated health care provider (physician or clinic) completes and signs the disclosure, adding pages if needed, and completes the certificate of mailing listing everyone copied.

Submitting and payment

How to submit it
Provide it to the requesting party within 5 days of the request, by mail or delivery, and complete the certificate of mailing on page 2.
Who pays
The form carries no fee.

Good to know

  • 'Ownership interest' means ownership in a business involved in providing medical care through which the physician can exercise direction and control.
  • 'Employment relationships' include every arrangement in which the provider is in an employer and employee relationship to perform medical services for pay.
  • The information must be updated when it changes so that it is current to within 30 days of the request date.
  • The fillable PDF (revision 11/07) cannot be saved; type the entries, then print the form.

Get the official form

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

Designated Health Care Provider Disclosure Form

Official pagePDF

Fill it with Vero

If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.

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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 fast must a Colorado designated provider answer a disclosure request?

Within 5 days of the request. Under C.R.S. 8-43-404(5)(a)(I)(A) and Rule 8-3, the designated provider must give the requesting party a list of ownership interests and employment relationships, current to within 30 days of the request date.

What must be disclosed on WC30?

Part I lists businesses or entities involved in providing medical care in which the provider has an ownership interest and can exercise direction and control. Part II lists employment relationships, or any interests for which the provider performs medical services in exchange for pay.

Who can request a WC30 disclosure?

Any interested party in the workers' compensation case, such as the injured worker. The provider sends the completed form to the requester and lists every person copied on the certificate of mailing.