Form C 30 PDF Details

When navigating the complexities of workers' compensation in Tennessee, the Form C-30, known as the Attending Physician's Report, plays a pivotal role in the process. This form, issued by the Tennessee Department of Labor and Workforce Development Division of Workers' Compensation, is a detailed document that must be filled out by the physician treating an injured worker. It serves multiple purposes, including reporting the nature and extent of the injury, the treatment administered, and the prognosis for recovery. Moreover, it delves into specifics such as the date and description of the accident, any contributing causes or preexisting conditions, and the anticipated or actual date of return to work, whether on a full-duty or light-duty basis. The form also covers aspects like hospitalization details, any potential for permanent disability, and, in unfortunate cases, the date of death. Essential to both the injured worker and the employer, the Form C-30 is a crucial tool in ensuring that the claims process is navigated efficiently and transparently. By requiring detailed medical information, it helps in the assessment and verification of workers' compensation claims, thereby aiming to prevent fraud and ensure that the injured worker receives the appropriate benefits and care, emphasizing the legal stipulation that knowingly providing false information is a crime punishable by imprisonment, fines, and denial of insurance benefits.

QuestionAnswer
Form NameForm C 30
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesbwcc30form, form c 30, c30a form tennessee, form c30

Form Preview Example

FORM C-30

TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT

Division of Workers' Compensation

220 French Landing Dr.

Nashville, Tennessee 37243-1002

ATTENDING PHYSICIAN'S 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.

 

1.

Name of Injured Person:

 

 

 

 

 

 

 

 

PATIENT

SSN:

 

 

Age:

 

Sex:

 

2.

Address:

 

 

City:

 

State:

 

Zip:

3.

Employer Name:

 

 

 

 

 

 

 

 

Address:

 

 

City:

 

State:

 

Zip:

 

 

 

 

 

ACCIDENT

4.

Date of Accident:

Hour:

AM/PM

 

Date of Disability:

5.

State in patient’s own words where and how accident occurred:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6.

Give accurate description of nature and extent of injury and state your objective findings:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

7.

Is accident referred to above only cause of patient’s condition?

 

 

 

INJURY

 

If not, state contributing causes:

 

 

 

 

 

 

 

 

8.

Is patient suffering from any disease of the heart, lungs, brain, kidneys, blood, vascular system or any

other disabling condition not due to this accident?

 

 

 

 

 

 

Give particulars:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

9.

Has patient any physical impairment due to previous accident or disease?

 

 

 

 

Give particulars:

 

 

 

 

 

 

 

 

 

10.

Has normal recovery been delayed for any reason?

 

 

 

 

Give particulars:

 

 

 

 

 

 

 

 

 

11.

Who engaged your services?

 

 

 

 

 

 

 

 

 

12.

Date of your first treatment:

 

 

 

 

 

 

 

 

TREATMENT

13.

Describe treatment given by you:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

14.

Was patient treated by anyone else?

 

When?

 

 

 

15.

Was patient hospitalized?

 

 

 

Name of hospital:

 

 

 

Address of hospital:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

16.

Date of admission to hospital:

 

 

 

Date of discharge:

 

 

17.

Is further treatment needed?

 

 

 

For how long?

 

 

 

DISABILITY

18.

Will the injury result in:

 

 

 

 

 

 

 

 

(a)

Permanent Defect?

 

If so, what?

 

 

 

(b) Facial or head disfigurement?

 

 

 

 

 

 

 

 

19.

Date able to return to work:

 

 

 

 

 

 

 

 

20. Date able to return to work light duty:

 

 

 

 

 

 

 

21.

If death ensued, give date:

 

 

 

 

 

 

 

 

 

Remarks: (Give any information of value not listed above)

 

 

 

 

 

 

 

 

 

 

This report must be signed personally by physician.

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of report:

 

 

 

Signed

 

 

 

 

Address:

 

 

 

Telephone:

 

 

 

LB-0022 (REV. 12/07)

RDA 10183

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1. The form c30 tennessee needs specific details to be entered. Make certain the following fields are completed:

Completing part 1 of form c30

2. After this part is filled out, go on to type in the applicable details in these: Give accurate description of, Date of discharge For how long, When Name of hospital, If so what, Date of report Address, Signed Telephone, T N E M T A E R T, Y T I L I B A S I D, and LB REV RDA.

form c30 writing process outlined (portion 2)

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