Tennessee > Workers Compensation
Case Manager Registration C-38 - Tennessee
| Case Manager Registration Form. This is a Tennessee form and can be used in Workers Compensation . |
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FORM C-38 TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT Division of Workers' Compensation 220 French Landing Dr. Nashville, Tennessee 37243-1002 CASE MANAGER REGISTRATION NAME: ______________________________________________________________________ TITLE: ______________________________________________________________________ CERTIFICATIONS: TYPE CERTIFICATION NUMBER DATE ISSUED DATE EXPIRES 1. 2. 3. R.N. LICENSE NUMBER: _________________ DATE OF EXPIRATION: _________________ M.D. LICENSE NUMBER: _________________ DATE OF EXPIRATION: ________________ STATE ISSUING LICENSE: __________ TEMPORARY__________ PERMANEMT________ IN ORDER TO PROCESS YOUR REGISTRATION, COPIES OF YOUR CURRENT R.N. OR M.D. LICENSE AND/OR CERTIFICATIONS MUST BE SUBMITTED WITH COMPLETED FORM. COMPANY NAME: ____________________________________________________________ COMPANY ADDRESS: ________________________________________________________ ________________________________________________________ ________________________________________________________ COMPANY TELEPHONE NUMBER: YOUR OFFICE PHONE NUMBER: FAX NUMBER: ( ( ( ) ____________________________ ) ____________________________ ) ____________________________ EMAIL ADDRESS: ___________________________________________________________ PLEASE LIST ANY PROVIDERS WITH WHOM YOU SELF CONTRACT: _____________________________________________________________________________ SIGNATURE: ________________________________________________________________ LB-0965 (REV. 10/11) RDA 10183 American LegalNet, Inc. www.FormsWorkFlow.com
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