Form C-31 Medical Waiver And Consent {LB-0379}

Tennessee Bureau of Workers' Compensation 220 French Landing Drive, I-B Nashville, TN 37243-1002 800-332-2667 FORM C-31 MEDICAL WAIVER AND CONSENT This form is not required for injuries occurring on or after July 1, 2014 THIS MEDICAL AUTHORIZATION FORM ONLY PERMITS THE EMPLOYER OR THE BUREAU OF WORKERS' COMPENSATION TO OBTAIN MEDICAL INFORMATION THROUGH ORAL OR WRITTEN COMMUNICATION, INCLUDING, BUT NOT LIMITED TO, CHARTS, FILES, RECORDS, AND REPORTS IN THE POSSESSION OF A MEDICAL PROVIDER AUTHORIZED BY THE EMPLOYER PURSUANT TO T.C.A. § 50-6-204 AND A MEDICAL PROVIDER THAT IS REIMBURSED BY THE EMPLOYER FOR THE EMPLOYEE'S TREATMENT. I, ______________________________, having filed a claim for workers' compensation benefits, do hereby authorize (Printed Patient Name) ______________________________________________________ to furnish to my employer or my employer's (Name of Medical Provider) representative, and/or the Bureau of Workers' Compensation any information or written material reasonably related to my work-related injury of _____________________for which I am claiming compensation. I further authorize the release of (Date of Injury) the same information to me or my attorney. The authorization includes, but is not restricted to, a right to review and obtain copies of all records, x-rays, x-ray reports, medical charts, prescriptions, diagnoses, opinions and courses of treatment. A photocopy of the authorization may be accepted in lieu of the original. __________________________________________________________________________________________________ Patient Signature Date Date of Birth LB-0379(REV11/15) RDA10183 American LegalNet, Inc. www.FormsWorkFlow.com