Tennessee > Workers Compensation
Provider Registration For Utilization Review C-39 - Tennessee
| Provider Registration For Utilization Review Form. This is a Tennessee form and can be used in Workers Compensation . |
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FORM C-39 TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT Division of Workers' Compensation 220 French Landing Dr. Nashville, Tennessee 37243-1002 PROVIDER REGISTRATION FOR UTILIZATION REVIEW COMPANY NAME: COMPANY ADDRESS: _____________________________________________________ _____________________________________________________ _____________________________________________________ _____________________________________________________ _____________________________________________________ TELEPHONE NUMBER: FAX NUMBER: EMAIL ADDRESS: _____________________________________________________ _____________________________________________________ _____________________________________________________ TN LICENSE (ASSIGNED BY COMMERCE & INSURANCE) ________________________ CREDENTIALS DATE ISSUED DATE EXPIRES _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ PLEASE LIST ANY PROVIDERS WITH WHOM YOU SUBCONTRACT: _____________________________________________________________________________ _____________________________________________________________________________ SUBMITTED BY ____________________________________ TITLE ________________________ LB-0968 (REV. 03/09) RDA 10183 American LegalNet, Inc. www.FormsWorkFlow.com
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