Tennessee Form C 30A PDF Details

When navigating the aftermath of a workplace injury in Tennessee, the importance of accurate and thorough documentation cannot be overstated. Among the key documents in this process is the Tennessee C-30A form, a critical piece of paperwork issued by the Tennessee Department of Labor and Workforce Development's Division of Workers' Compensation. Designed to be filled out by the treating physician, this form captures essential details about the injured worker's medical condition, the extent of any permanent impairments resulting from the injury, and the ability (or inability) of the injured worker to return to work. Even more critical, the form serves as a linchpin in determining eligibility for workers' compensation benefits, playing a direct role in defining the scope of those benefits. It outlines specifics such as the injury date, the claimant's details, the employer and insurer information, and, importantly, a section on whether the injury has led to any permanent impairment, specifying the extent and body part affected. The form also makes it clear that providing false information can lead to severe penalties, including imprisonment, fines, and denial of insurance benefits. For anyone involved in a workers' compensation case in Tennessee, understanding the C-30A form and ensuring its accurate completion is a step that cannot be overlooked.

QuestionAnswer
Form NameTennessee Form C 30A
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesc30a forms tn, c30 a form, tn c30 a form, c30a form

Form Preview Example

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.

DATE OF MAXIMUM MEDICAL IMPROVEMENT _________________________.

3.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

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