Request For Investigation {LB-3304}

FORM C-33 TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT Division of Workers' Compensation 220 French Landing Dr. Nashville, Tennessee 37243-1002 CASE MANAGEMENT NOTIFICATION EMPLOYEE INFORMATION Social Security #_______________ State File # ______________ Date of Injury Claimant _______________________________________________________________________ EMPLOYER INFORMATION FEIN: ___________________ Employer: ______________________________________________ State: Zip: __________ Street: __________________________ City: INSURER INFORMATION Insurer: _______________________________________________________________________ Insurer Address: ____________________________________________________________________ Insurer Claim #: ____________________________ Policy Number: _____________________ CASE MANAGEMENT ELECTION _____ Proof of notification has been provided to employee that employer has elected to use Case Management. PROVIDER INFORMATION Case Management Provider _______________________________________ I.D. # ______ Case Management Provider Address ______________________________________________ ____________________________________________________ ____________________________________________________ CASE MANAGER INFORMATION Case Management Provider Phone # ______________________________________________ Date Case Manager received referral ______________________________________________ Date Face to Face Meeting took place between CM and Employee ____________________________________________________________________________ Case Manager __________________________________ TN CM Registration # ________ Comments __________________________________________________________________ ____________________________________________________________________________ LB-0376 (REV. 09/08) RDA 10183 www.FormsWorkFlow.com