Final Medical Report {C-30A}

LB-0383 (REV 1/17) RDA 10183 220 French Landing Drive, I-B Nashville, TN 37243-1002 800-332-2667 FORM C-30A FINAL MEDICAL REPORT This Report is to be completed by the treating physician and provided to the adjuster or insurance carrier within 21 days of the date the injured worker has reached Maximum Medical Improvement (MMI). STATE FILE # DATE OF INJURY DATE OF MMI PATIENT NAME SSN EMPLOYER INSURANCE CARRIER IN YOUR MEDICAL OPINION, ON WHAT DATE WAS THE PATIENT ABLE TO RETURN TO WORK, WITH RESTRICTIONS? WITHOUT RESTRICTIONS? IF APPLICABLE, WHAT WERE THE DATES WHEN THE PATIENT WAS UNABLE TO WORK? FROM TO DO YOU ANTICIPATE THE NEED FOR FUTURE MEDICAL TREATMENT FOR THIS INJURY? YES NO DID THE INJURY RESULT IN PERMANENT IMPAIRMENT? YES NO IF YES, COMPLETE THE FOLLOWING: (USE THE 6th EDITION OF AMA GUIDES256 TO DETERMINE THE IMPAIRMENT RATING) FOR INJURIES ON OR AFTER JULY 1, 2014 PERCENTAGE TO THE BODY AS A WHOLE FOR INJURIES PRIOR TO JULY 1, 2014 PERCENTAGE to BODY PART LEFT RIGHT PERCENTAGE to BODY PART LEFT RIGHT PERCENTAGE to BODY PART LEFT RIGHT This Report must be completed, signed and dated by the treating physician only. PHYSICIAN SIGNATURE DATE PHYSICIAN NAME (Printed) MED LICENSE # STATE American LegalNet, Inc. www.FormsWorkFlow.com