Free APPENDIX A - Tennessee

FORM C-30A TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT Division of Workers' Compensation 220 French Landing Dr. Nashville, Tennessee 37243-1002

FINAL MEDICAL REPORT It is a crime to knowingly provide false, incomplete or misleading information to any party to a workers' compensation transaction for the purpose of committing fraud. Penalties include imprisonment, fines and denial of insurance benefits.
INSTRUCTIONS: FORM TO BE COMPLETED BY THE PHYSICIAN. STATE FILE # ___________________________________ INJURY DATE ________________________ CLAIMANT _____________________________________ SOC. SEC. # __________________________ EMPLOYER ___________________________________________________________________________ INSURER _______________________________________ INS. CLAIM #

1.

RETURN TO WORK DATE:

________________ RESTRICTED DUTY ________________ REGULAR DUTY

2. 3.

DATE OF MAXIMUM MEDICAL IMPROVEMENT _________________________. DID INJURY RESULT IN PERMANENT IMPAIRMENT? _____NO _______YES IF YES, GIVE THE FOLLOWING:

_____________ PERCENTAGE __________________ BODY PART _________ LEFT _______ RIGHT _____________ PERCENTAGE __________________ BODY PART _________ LEFT _______ RIGHT

4.

EDITION OF AMA GUIDES USED TO DETERMINE RATING ________ __________________

REPORT MUST BE DATED AND SIGNED BY THE PHYSICIAN. DATE _____________ PHYSICIAN_________________________________________________________

The copy to be filed with the Division can be provided by Fax, (615) 532-8546, or by mail, Workers' Compensation Division, 220 French Landing Drive, Nashville, TN 37243-1002.
LB0383 (REV. 01/09)
RDA 10183