Application For Registration For Utilization Review Organization {LB-0968}

Tennessee Bureau of Workers' Compensation 220 French Landing Drive, I-B Nashville, TN 37243-1002 800-332-2667 FORM C-39 APPLICATION FOR REGISTRATION FOR UTILIZATION REVIEW ORGANIZATION ORGANIZATION NAME ___________________________________________________________________ ADDRESS 1 ______________________________________________________________________________ ADDRESS 2 ______________________________________________________________________________ CITY _____________________________________ STATE ________ ZIP ____________________________ CONTACT NAME AND TITLE ______________________________________________________________ EMAIL _________________________________ PHONE __________________________ FAX ________________________ DATE EXPIRES CERTIFICATION DATE ISSUED __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ SUBMITTED BY (Please print) ______________________________________________ TITLE ____________________ Please provide the following documents with this application: · A copy of the "Approved" certification letter, issued by the Tennessee Department of Commerce and Insurance; and, · Proof of all certifications listed above. By my signature below, I certify that the information provided on this application is true and accurate, to the best of my knowledge. Signature Date LB-0968 (REV 11/15) RDA 10183 American LegalNet, Inc. www.FormsWorkFlow.com