Designation of Medical Providers Brakes Plus, Inc. hereby designates the following medical providers to provide treatment for your work related injuries: Please select a provider from the following list, write the name, address and phone number of the provider you have chosen to treat with and sign and date below where indicated. Provider Name: Provider Address: Provider City State Zip: Provider Phone: Printed Name of Employee Signed Name of Employee Date of Signature The name and contact information of our authorized representative is: Krysti Giese - HR Director 6911 S Yosemite St, Centennial, CO 80112 303-221-8600 x244 kgiese@brakesplus.com The name and address of our insurer/third party administrator is: Travelers Insurance Company PO Box 173762 Denver, CO 80217-3762 Phone: 800-227-1538 Fax: 877-801-9674 If you have any questions, please contact our authorized representative or insurer/third party administrator.
Providers marked with a ** or * are Preferred Providers with Travelers Insurance. This means they have better communication with the docs. You are not required to choose one of these. You may choose any of the providers listed for your store. If you would prefer to go to another provider listed for a different store because they are closer to your home, that is acceptable. As long as the provider is on this list, they are approved for you to choose from. Colorado law requires an employer to provide 4 Occupational Medicine Providers for an injured worker to choose from. This list shows the closest Designated Providers to your stores. In most cases these are less than 10 miles from your store. In rural areas, availability is much less, therefore there may be two different providers at the same location, or one or more providers may be significantly more than 10 miles away. 100 * Concentra Medical Center 7150 S Fulton St Bldg 200 C Englewood, CO 80112 P 866-530-3940 100 * Arbor Occupational Medicine 8200 E Belleview Ave Ste 428-C Greenwood Village, CO 80111 P 303-741-1166 100 ** Concentra Medical Center 11877 E Arapahoe Rd Suite 100 Centennial, CO 80112 P 303-792-7368, 888-997-2669 100 East - West Health Centers 8200 E Belleview Ave Ste 202 C Greenwood Village, CO 80111 P 303-694-5757 100 * Healthone 14000 E Arapahoe Rd Ste 160 Centennial, CO 80112 P 303-218-4250 101 * Arbor Occupational Medicine 8200 E Belleview Ave Ste 428-C Greenwood Village, CO 80111 P 303-741-1166 101 * Concentra Medical Center 7150 S Fulton St Bldg 200 C Englewood, CO 80112 P 866-530-3940 101 ** Concentra Medical Center 11877 E Arapahoe Rd Suite 100 Centennial, CO 80112 P 303-792-7368, 888-997-2669 101 East - West Health Centers 8200 E Belleview Ave Ste 202 C Greenwood Village, CO 80111 P 303-694-5757 101 * Healthone 14000 E Arapahoe Rd Ste 160 Centennial, CO 80112 P 303-218-4250 102 * CCOM South Denver 20 W Dry Creek Cir Ste 300 Littleton, CO 80120 P 303-269-2900 102 * Concentra Medical Center 20 W Dry Creek Cir Ste 100 Littleton, CO 80120 P 303-798-1009 102 * Healthone 125 E Hampden Ave Englewood, CO 80113 P 303-788-9200 102 Lutheran Southwest Urgent Care 13402 W Coal Mine Ave Ste 110 Littleton, CO 80127 P 303-403-6520 103 * Concentra Medical Center 10355 E Iliff Ave Aurora, CO 80247 P 303-755-4955 103 * Healthone 1444 S Potomac St Ste 210 Aurora, CO 80012 P 303-214-0330, 303-806-5500 103 * Nextcare Urgent Care 18890 E Hampden Ave Aurora, CO 80013 P 303-617-1604 103 * Rocky Mountain Family Medicine 13650 E Mississippi Ave Ste 110 Aurora, CO 80012 P 303-695-8684, 303-872-1980 104 * CCOM South Denver 20 W Dry Creek Cir Ste 300 Littleton, CO 80120 P 303-269-2900 104 * Concentra Medical Center 20 W Dry Creek Cir Ste 100 Littleton, CO 80120 P 303-798-1009 104 Exempla Healthcare 12790 W Alameda Pkwy Ste A Lakewood, CO 80228 P 303-403-6350 104 * Healthone 125 E Hampden Ave Englewood, CO 80113 P 303-788-9200 104 Lutheran Southwest Urgent Care 13402 W Coal Mine Ave Ste 110 Littleton, CO 80127 P 303-403-6520 105 * Arbor Occupational Medicine 290 Nickel St Ste 200 Broomfield, CO 80020 P 303-460-9339 105 CCOM/North Denver 8510 Bryant St Ste 360 Westminster, CO 80031 P 303-650-7973 105 * Concentra Medical Center 7401 Church Ranch Rd Bldg 2 Ste 202 Westminster, CO 80021 P 303-282-4009 105 Exempla Northwest Medical Center 4750 W 120th Ave Ste 100 Westminster, CO 80020 P 303-469-1988 106 * Concentra Medical Center 500 E 84th Ave Ste B14 Thornton, CO 80229 P 303-287-7070 106 * Healthone 12207 Pecos St Ste 300 Westminster, CO 80234 P 303-650-6520 106 * Healthone 9195 Grant St Ste 100 Denver, CO 80229 P 303-292-0034, 303-451-7700 106 * Occ Med Colorado 550 Thornton Pkwy Ste 110 Thornton, CO 80229 P 720-872-0399 107 CO Rehab and Occupational 9399 Crown Crest Blvd Ste 240 Parker, CO 80138 P 303-341-4785 107 ** Concentra Medical Center 11877 E Arapahoe Rd Suite 100 Centennial, CO 80112 P 303-792-7368, 888-997-2669
107 * Healthone 14000 E Arapahoe Rd Ste 160 Centennial, CO 80112 P 303-218-4250 107 University Medicine Anschutz Medical 1635 Aurora CT Ste 5600 Aurora, CO 80045 P 720-848-2300 108 * Concentra Medical Center 2490 W 26th Ave Denver, CO 80211 P 303-433-2300 108 Exempla Healthcare 9830 I-70 Frontage Rd S Wheat Ridge, CO 80033 P 303-467-4100 108 * Healthone 1515 Wazee St Ste D Denver, CO 80202 P 303-534-9550, 303-534-9553 108 Rocky Mountain Urgent Care 6080 W 92nd Ave Westminster, CO 80031 P 303-429-9311, 303-762-0900 109 * Concentra Medical Center 500 E 84th Ave Ste B14 Thornton, CO 80229 P 303-287-7070 109 Exempla Thornton Medical Center 1181 E 120th Ave Unit A Thornton, CO 80233 P 303-673-1500 109 * Healthone 9195 Grant St Ste 100 Denver, CO 80229 P 303-292-0034, 303-451-7700 109 * Occ Med Colorado 550 Thornton Pkwy Ste 110 Thornton, CO 80229 P 720-872-0399 110 CO Rehab and Occupational 401 W Hampden Pl Ste 220 Englewood, CO 80110 P 303-341-0722 110 * Concentra Medical Center 1212 S Broadway Ste 100 Denver, CO 80210 P 303-433-2300, 303-777-2777 110 * Healthone 125 E Hampden Ave Englewood, CO 80113 P 303-788-9200 110 Rocky Mountain Medical Group 730 W Hampden Ave Ste 200 Englewood, CO 80110 P 303-762-0900 111 * Concentra Medical Center 605 Parfet St Ste 103 Lakewood, CO 80215 P 303-462-3627, 866-944-6046 111 Exempla Healthcare 12790 W Alameda Pkwy Ste A Lakewood, CO 80228 P 303-403-6350 111 * Healthone 120 Bryant St Denver, CO 80219 P 303-936-9700, 303-937-6112 111 Union Medical PC 200 Union Blvd Ste 318 Lakewood, CO 80228 P 303-985-1811 112 * Arbor Occupational Medicine 8200 E Belleview Ave Ste 428-C Greenwood Village, CO 80111 P 303-741-1166 112 * CCOM South Denver 20 W Dry Creek Cir Ste 300 Littleton, CO 80120 P 303-269-2900 112 * Concentra Medical Center 9330 S University Blvd Ste 100 Highlands Ranch, CO 80126 P 303-346-3627 112 * Healthone 125 E Hampden Ave Englewood, CO 80113 P 303-788-9200 114 * Concentra Medical Center 620 S Lemay Ave Fort Collins, CO 80524 P 866-944-6046, 970-482-6620 114 * Occupational Health Services 4674 Snow Mesa Dr Ste 200 Fort Collins, CO 80528 P 970-495-8450 114 PVMG-Occupational Health Services 1330 Oakridge Dr Fort Collins, CO 80525 P 970-495-8895 114 Workwell Occupational Medicine 1600 Specht Point Rd Ste 115 Fort Collins, CO 80525 P 970-672-5100 115 * Banner Occupational Health 1703 E 18th St Ste 4 Loveland, CO 80538 P 970-278-4580 115 * Concentra Medical Center 620 S Lemay Ave Fort Collins, CO 80524 P 866-944-6046, 970-482-6620 115 * Occupational Health Services 2500 Rocky Mountain Ave Ste 330 Loveland, CO 80538 P 970-624-3350 115 * Workwell Occupational Medicine 1608 Topaz Dr Loveland, CO 80537 P 303-827-3158, 970-593-0125 116 * Arbor Occupational Medicine 1860 Industrial Cir Ste D Longmont, CO 80501 P 303-682-2473 116 * Concentra Medical Center 3300 N 28th St Boulder, CO 80301 P 303-541-9090, 719-592-1584 116 Exempla Healthcare 8350 Colorado Blvd Ste 160 Firestone, CO 80504 P 303-689-5160 116 * Workwell Occupational Medicine 205 S Main St Ste C Longmont, CO 80501 P 303-702-1612 117 Banner Occupational Health 1517 16th Avenue CT Greeley, CO 80631 P 970-350-6810 117 * Occupational Health Services 2500 Rocky Mountain Ave Ste 330 Loveland, CO 80538 P 970-624-3350 117 PVMG-Occupational Health Services 1900 16th St Greeley, CO 80631 P 970-350-2471 117 Workwell Occupational Medicine 2528 W 16th St Greeley, CO 80634 P 970-356-9800 118 Broadmoor Medical Clinic 1299 Lake Plaza Dr Colorado Springs, CO 80906 P 719-527-1728 118 * Concentra Medical Center 2322 S Academy Blvd Colorado Springs, CO 80916 P 719-390-1727 118 * CSSC at Circle 3030 N Circle Dr Ste 217 Colorado Springs, CO 80909 P 719-766-4888, 719-776-4726 118 Pikes Peak Physical Medicine 2955 Professional Pl Ste 201 Colorado Springs, CO 80904 P 719-591-0011
119 Broadmoor Medical Clinic 1299 Lake Plaza Dr Colorado Springs, CO 80906 P 719-527-1728 119 * Concentra Medical Center 5320 Mark Dabling Blvd # 100 Colorado Springs, CO 80918 P 719-592-1584 119 * CSSC at Circle 3030 N Circle Dr Ste 217 Colorado Springs, CO 80909 P 719-766-4888, 719-776-4726 119 Pikes Peak Physical Medicine 2955 Professional Pl Ste 201 Colorado Springs, CO 80904 P 719-591-0011 120 Broadmoor Medical Clinic 1299 Lake Plaza Dr Colorado Springs, CO 80906 P 719-527-1728 120 * Concentra Medical Center 5320 Mark Dabling Blvd # 100 Colorado Springs, CO 80918 P 719-592-1584 120 * CSSC at Circle 3030 N Circle Dr Ste 217 Colorado Springs, CO 80909 P 719-766-4888, 719-776-4726 120 Pikes Peak Physical Medicine 2955 Professional Pl Ste 201 Colorado Springs, CO 80904 P 719-591-0011 121 * Centura 6011 E Woodmen Rd Ste 100 Colorado Springs, CO 80923 P 719-571-8888, 719-574-8383 121 * Concentra Medical Center 5320 Mark Dabling Blvd # 100 Colorado Springs, CO 80918 P 719-592-1584 121 Healthquest Medical Inc 1495 Garden of The Gods Rd Ste 102 Colorado Springs, CO 80907 P 719-260-9797 121 Pikes Peak Physical Medicine 2955 Professional Pl Ste 201 Colorado Springs, CO 80904 P 719-591-0011 122 Excel Physical Occupational Therapy 4117 N Elizabeth St Pueblo, CO 81008 P 719-545-0788 122 Pikes Peak Physical Medicine 509 Colorado Ave Ste C Pueblo, CO 81004 P 719-566-8010 122 * Pueblo CCOM 4112 Outlook Blvd Ste 255 Pueblo, CO 81008 P 719-562-6300 122 Total Healthcare 4112 Outlook Blvd Ste 37 Pueblo, CO 81008 P 719-562-6300 123 Excel Physical Occupational Therapy 4117 N Elizabeth St Pueblo, CO 81008 P 719-545-0788 123 Pikes Peak Physical Medicine 509 Colorado Ave Ste C Pueblo, CO 81004 P 719-566-8010 123 * Pueblo CCOM 4112 Outlook Blvd Ste 255 Pueblo, CO 81008 P 719-562-6300 123 Total Healthcare 4112 Outlook Blvd Ste 37 Pueblo, CO 81008 P 719-562-6300 124 * Arbor Occupational Medicine 8200 E Belleview Ave Ste 428-C Greenwood Village, CO 80111 P 303-741-1166 124 ** Concentra Medical Center 11877 E Arapahoe Rd Suite 100 Centennial, CO 80112 P 303-792-7368, 888-997-2669 124 * Healthone 14000 E Arapahoe Rd Ste 160 Centennial, CO 80112 P 303-218-4250 124 * Rocky Mountain Family Medicine 13650 E Mississippi Ave Ste 110 Aurora, CO 80012 P 303-695-8684, 303-872-1980 125 * Arbor Occupational Medicine 8200 E Belleview Ave Ste 428-C Greenwood Village, CO 80111 P 303-741-1166 125 * CCOM South Denver 20 W Dry Creek Cir Ste 300 Littleton, CO 80120 P 303-269-2900 125 * Concentra Medical Center 9330 S University Blvd Ste 100 Highlands Ranch, CO 80126 P 303-346-3627 125 ** Concentra Medical Center 11877 E Arapahoe Rd Suite 100 Centennial, CO 80112 P 303-792-7368, 888-997-2669 125 * Healthone 14000 E Arapahoe Rd Ste 160 Centennial, CO 80112 P 303-218-4250 126 * Arbor Occupational Medicine 8200 E Belleview Ave Ste 428-C Greenwood Village, CO 80111 P 303-741-1166 126 * CCOM South Denver 20 W Dry Creek Cir Ste 300 Littleton, CO 80120 P 303-269-2900 126 * Concentra Medical Center 7150 S Fulton St Bldg 200 C Englewood, CO 80112 P 866-530-3940 126 ** Concentra Medical Center 11877 E Arapahoe Rd Suite 100 Centennial, CO 80112 P 303-792-7368, 888-997-2669 126 * Healthone 14000 E Arapahoe Rd Ste 160 Centennial, CO 80112 P 303-218-4250 126 * Rocky Mountain Family Medicine 13650 E Mississippi Ave Ste 110 Aurora, CO 80012 P 303-695-8684, 303-872-1980 127 * Arbor Occupational Medicine 8200 E Belleview Ave Ste 428-C Greenwood Village, CO 80111 P 303-741-1166 127 * Concentra Medical Center 875 S Colorado Blvd Denver, CO 80246 P 303-388-3627 127 * Healthone 120 Bryant St Denver, CO 80219 P 303-936-9700, 303-937-6112 127 * Rocky Mountain Family Medicine 13650 E Mississippi Ave Ste 110 Aurora, CO 80012 P 303-695-8684, 303-872-1980 128 * Arbor Occupational Medicine 290 Nickel St Ste 200 Broomfield, CO 80020 P 303-460-9339 128 Boulder Community Medical Center 1000 W South Boulder Rd Ste 100 Lafayette, CO 80026 P 303-604-4664, 303-666-4357 128 * Concentra Medical Center 7401 Church Ranch Rd Bldg 2 Ste 202 Westminster, CO 80021 P 303-282-4009
128 Exempla Northwest Family & Occ Med 12169 Sheridan Blvd Broomfield, CO 80020 P 303-603-9400 129 * Arbor Occupational Medicine 8200 E Belleview Ave Ste 428-C Greenwood Village, CO 80111 P 303-741-1166 129 * Concentra Medical Center 875 S Colorado Blvd Denver, CO 80246 P 303-388-3627 129 * Healthone 125 E Hampden Ave Englewood, CO 80113 P 303-788-9200 129 * Rocky Mountain Family Medicine 13650 E Mississippi Ave Ste 110 Aurora, CO 80012 P 303-695-8684, 303-872-1980 130 * Centura 6011 E Woodmen Rd Ste 100 Colorado Springs, CO 80923 P 719-571-8888, 719-574-8383 130 * Concentra Medical Center 5320 Mark Dabling Blvd # 100 Colorado Springs, CO 80918 P 719-592-1584 130 * CSSC at Circle 3030 N Circle Dr Ste 217 Colorado Springs, CO 80909 P 719-766-4888, 719-776-4726 130 Edge Rehabilitation and Wellness 6985 Tutt Blvd Colorado Springs, CO 80923 P 719-599-5330 130 Pikes Peak Physical Medicine 2955 Professional Pl Ste 201 Colorado Springs, CO 80904 P 719-591-0011 131 Broadmoor Medical Clinic 1299 Lake Plaza Dr Colorado Springs, CO 80906 P 719-527-1728 131 * Concentra Medical Center 2322 S Academy Blvd Colorado Springs, CO 80916 P 719-390-1727 131 * CSSC at Circle 3030 N Circle Dr Ste 217 Colorado Springs, CO 80909 P 719-766-4888, 719-776-4726 131 Pikes Peak Physical Medicine 2955 Professional Pl Ste 201 Colorado Springs, CO 80904 P 719-591-0011 132 Broadmoor Medical Clinic 1299 Lake Plaza Dr Colorado Springs, CO 80906 P 719-527-1728 132 * Concentra Medical Center 2322 S Academy Blvd Colorado Springs, CO 80916 P 719-390-1727 132 * CSSC at Circle 3030 N Circle Dr Ste 217 Colorado Springs, CO 80909 P 719-766-4888, 719-776-4726 132 Edge Rehabilitation and Wellness 2150 Hollow Brook Dr Ste 100 Colorado Springs, CO 80918 P 719-599-5330 133 * Concentra Medical Center 15235 E 38th Ave Aurora, CO 80011 P 303-340-3053, 888-997-2669 133 Exempla Healthcare 2803 Roslyn St Denver, CO 80238 P 303-403-6300 133 * Healthone 1444 S Potomac St Ste 210 Aurora, CO 80012 P 303-214-0330, 303-806-5500 133 * Rocky Mountain Family Medicine 13650 E Mississippi Ave Ste 110 Aurora, CO 80012 P 303-695-8684, 303-872-1980 134 * Arbor Occupational Medicine 8200 E Belleview Ave Ste 428-C Greenwood Village, CO 80111 P 303-741-1166 134 CO Rehab and Occupational 9399 Crown Crest Blvd Ste 240 Parker, CO 80138 P 303-341-4785 134 ** Concentra Medical Center 11877 E Arapahoe Rd Suite 100 Centennial, CO 80112 P 303-792-7368, 888-997-2669 134 * Healthone 14000 E Arapahoe Rd Ste 160 Centennial, CO 80112 P 303-218-4250 135 * Concentra Medical Center 5855 E Stapleton Dr N Ste A-130 Denver, CO 80216 P 303-371-7444 135 Exempla Healthcare 2803 Roslyn St Denver, CO 80238 P 303-403-6300 135 * Healthone 1515 Wazee St Ste D Denver, CO 80202 P 303-534-9550, 303-534-9553 135 * Rocky Mountain Family Medicine 13650 E Mississippi Ave Ste 110 Aurora, CO 80012 P 303-695-8684, 303-872-1980 136 CO Rehab and Occupational 2646 Patterson Rd Ste A Grand Junction, CO 81506 P 303-341-0722 136 Grand Valley Urgent Care 1060 Orchard Ave Ste N Grand Junction, CO 81501 P 970-256-6345 136 St. Mary`s Occupational Health 2686 Patterson Rd Grand Junction, CO 81506 P 970-298-2001, 970-244-2001 136 WorkPartners 2646 Patterson Rd Ste A Grand Junction, CO 81506 P 970-241-5585, 303-341-0722 137 CO Rehab and Occupational 9399 Crown Crest Blvd Ste 240 Parker, CO 80138 P 303-341-4785 137 * Concentra Medical Center 9330 S University Blvd Ste 100 Highlands Ranch, CO 80126 P 303-346-3627 137 * Premier Occupational Medicine 15854 Jackson Creek Pkwy Unit 120 Monument, CO 80132 P 719-481-2335 137 Rocky Mountain Medical Group 4348 Woodlands Blvd Ste 100 Castle Rock, CO 80104 P 303-650-6201