Free APPENDIX A - Tennessee

FORM C-39 TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT Division of Workers' Compensation 220 French Landing Dr. Nashville, Tennessee 37243-1002

PROVIDER REGISTRATION FOR UTILIZATION REVIEW

COMPANY NAME: COMPANY ADDRESS:

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TELEPHONE NUMBER: FAX NUMBER: EMAIL ADDRESS:

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TN LICENSE (ASSIGNED BY COMMERCE & INSURANCE) ________________________ CREDENTIALS DATE ISSUED DATE EXPIRES

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PLEASE LIST ANY PROVIDERS WITH WHOM YOU SUBCONTRACT:

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SUBMITTED BY ____________________________________ TITLE ________________________

LB-0968 (REV. 03/09)

RDA 10183