Ime 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the Claimant Name, DIME Physician, WC #, Date of Injury, Appointment Date, and Report Due Date in the designated fields.
3. Indicate whether the claimant is at Maximum Medical Improvement (MMI) for this injury by selecting 'Yes' or 'No' and providing the date if applicable.
4. Fill out the DIME Physician’s Rating section by entering the percentage of Whole Person (WP) impairment for each body part listed: Spine, Extremities (Right/Left upper/lower), Psychological, and Other. Ensure to calculate and enter both Final Combined Unapportioned and Apportioned Impairment Ratings.
5. Sign and date the form in the Signature section to validate your entries.
6. Review all sections to ensure completeness before submitting your report within 20 calendar days from the appointment date.

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