Free APPENDIX A - Tennessee

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