Tennessee > Workers Compensation
Attending Physicians Report C-30 - Tennessee
| Attending Physicians Report Form. This is a Tennessee form and can be used in Workers Compensation . |
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C-30 TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT Division of Workers Compensation Nashville, Tennessee 37243-0661 ATTENDING PHYSICIANS REPORT It is a crime to knowingly provide false, incomplete or misleading information to any party to a workers compensation transaction for the purpose of committing fraud. Penalties include imprisonment, fines and denial of insurance benefits. THE 1. Name of Injured Person: SSN: Age: Sex: PATIENT 2. Address: City: State: Zip: 3. Employer Name: Address: City: State: Zip:THE 4. Date of Accident: Hour: AM/PM Date of Disability: 5. State in patients own words where and how accident occurred: ACCIDENT 6. Give accurate description of nature and extent of injury and state your objective findings:THE 7. Is accident referred to above only cause of patients condition? If not, state contributing causes: INJURY 8. Is patient suffering from any disease of the heart, lungs, brain, kidneys, blood, vascular system or any other disabling condition not due to this accident? Give particulars: 9. Has patient any physical impairment due to previous accident or disease? Give particulars: 10. Has normal recovery been delayed for any reason? Give particulars: 11. Who engaged your services? TREAT- 12. Date of your first treatment: MENT 13. Describe treatment given by you: 14. Was patient treated by anyone else? When? 15. Was patient hospitalized? Name of hospital: Address of hospital: 16. Date of admission to hospital: Date of discharge: 17. Is further treatment needed? For how long? 18. Will the injury result in: DIS- (a) Permanent Defect? If so, what? ABILITY (b) Facial or head disfigurement? 19. Date able to return to work: 20. Date able to return to work light duty: 21. If death ensued, give date: Remarks: (Give any information of value not listed above) This report must be signed personally by physician. Date of report: Signed Address: Telephone: LB-0022 (rev. 8/99)
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