Tennessee > Workers Compensation
Final Medical Report C-30A - Tennessee
| Final Medical Report Form. This is a Tennessee form and can be used in Workers Compensation . |
|
||||||
 Get this form for FREE as a print-only pdf |
|||||||
|
FORM C-30A TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT Division of Workers' Compensation 220 French Landing Dr. Nashville, Tennessee 37243-1002 FINAL MEDICAL 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. INSTRUCTIONS: FORM TO BE COMPLETED BY THE PHYSICIAN. STATE FILE # ___________________________________ INJURY DATE ________________________ CLAIMANT _____________________________________ SOC. SEC. # __________________________ EMPLOYER ___________________________________________________________________________ INSURER _______________________________________ INS. CLAIM # 1. RETURN TO WORK DATE: ________________ RESTRICTED DUTY ________________ REGULAR DUTY 2. 3. DATE OF MAXIMUM MEDICAL IMPROVEMENT _________________________. DID INJURY RESULT IN PERMANENT IMPAIRMENT? _____NO _______YES IF YES, GIVE THE FOLLOWING: _____________ PERCENTAGE __________________ BODY PART _________ LEFT _______ RIGHT _____________ PERCENTAGE __________________ BODY PART _________ LEFT _______ RIGHT 4. EDITION OF AMA GUIDES USED TO DETERMINE RATING ________ __________________ REPORT MUST BE DATED AND SIGNED BY THE PHYSICIAN. DATE _____________ PHYSICIAN_________________________________________________________ The copy to be filed with the Division can be provided by Fax, (615) 532-8546, or by mail, Workers' Compensation Division, 220 French Landing Drive, Nashville, TN 37243-1002. LB0383 (REV. 01/09) RDA 10183 American LegalNet, Inc. www.FormsWorkFlow.com
|
|||||||
