Free APPENDIX A - Tennessee

FORM C-38 TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT Division of Workers' Compensation 220 French Landing Dr. Nashville, Tennessee 37243-1002

CASE MANAGER REGISTRATION NAME: ______________________________________________________________________ TITLE: ______________________________________________________________________ CERTIFICATIONS: 1. 2. 3. 4.
TYPE CERTIFICATION NUMBER DATE ISSUED DATE EXPIRES

TN. LICENSE NUMBER

TEMPORARY _____________PERMANENT ____________

R.N. _________________________ DATE OF EXPIRATION _________________________ M.D. ________________________ DATE OF EXPIRATION__________________________ COMPANY NAME: ____________________________________________________________ COMPANY ADDRESS: ________________________________________________________ ________________________________________________________ ________________________________________________________ COMPANY TELEPHONE NUMBER: _____________________________________________ YOUR OFFICE PHONE NUMBER: _______________________________________________ FAX NUMBER: ______________________________________________________________ EMAIL ADDRESS: ___________________________________________________________ PLEASE LIST ANY PROVIDERS WITH WHOM YOU SELF CONTRACT: _____________________________________________________________________________ SIGNATURE: ________________________________________________________________

LB-0965 (REV. 03/09)

RDA 10183