Free Dear - Tennessee

FORM C-47

STATE OF TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT DIVISION OF WORKERS' COMPENSATION
220 FRENCH LANDING DRIVE NASHVILLE, TENNESSEE 37243-1002 PHONE: 1-800-332-2667 FAX: (615) 253-5265

MEDICAL CARE COST CONTAINMENT COMMITTEE REVIEW REQUEST
State File #: __________________ Requesting Party: ___________________________________ Mailing Address: ________________________________________________________________ State & Zip: _________________ Email Address: _____________________________________ Claimant Name: _________________________________________________________________ Employer: _____________________________________________________________________ Insurer: ________________________________________________________________________ Adjuster's Name: ________________________________________________________________ Adjuster's Email Address: ________________________________________________________________

1) Has the bill been sent for reconsideration? ________________________________________________ 2) If so, by whom? ______________________________________________________________________ 3) What were the findings? _______________________________________________________________ _______________________________________________________________________________________ 4) 5) 6) Has the bill been reviewed for appropriateness of treatment? __________________________________ If so, by whom? ______________________________________________________________________ What were the findings? _______________________________________________________________

________________________________________________________________________________________

Attach the initial EOR and the reconsideration EOR. Submit pertinent records and bills. Include a summary of the dispute and any attempts that were made to resolve the dispute.
____________________________________ _______________ __________________

Signature of Requesting Party
LB-1017

Date of Request

Telephone Number
RDA 10183