Free APPENDIX A - Tennessee

FORM C-35

TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT
Division of Workers' Compensation 220 French Landing Dr. Nashville, Tennessee 37243-1002 UTILIZATION REVIEW NOTIFICATION EMPLOYEE INFORMATION State File # ______________ Date of Injury Social Security #_______________ Claimant _______________________________________________________________________ EMPLOYER INFORMATION FEIN: ___________________ Employer: ________________________________________________ Street: __________________________ City: State: Zip: ____________ INSURER INFORMATION Insurer: _________________________________________________________________________ Insurer Address: ______________________________________________________________________ Insurer Claim #: ____________________________ Policy Number: _______________________ UTILIZATION REVIEW INFORMATION Utilization review has been instituted because of at least one of the following. Please check the applicable threshold(s). _____ Outpatient case where the injury results in medical costs in excess of five thousand dollars (5,000) _____ In-patient hospital admission _____ Other, explain __________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ Utilization Review Provider______________________________________________________________ TN Registration Number ________________________________________________________________ Utilization Review Provider Address_______________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ Utilization Review Provider Phone # ______________________________________________________ Utilization Review Provider Contact Person _________________________________________________ Date Utilization Review Initiated _________________________________________________________ Comments ___________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________
LB-0380 (REV. 12/07) RDA 10183