Form C-30A at a glance
What it is: Form C-30A is the Final Medical Report of the Tennessee Bureau of Workers' Compensation.
Who signs: Only the treating physician completes, signs and dates this report.
A filled-in Form C-30A example: a physician reports the final medical findings
How to fill out Form C-30A, box by box
State file number, date of injury and date of MMI
Enter the State File #, the Date of Injury and the Date of MMI.
Patient name, SSN, employer and insurance carrier
Enter the Patient Name and the SSN.
Enter the Employer.
Enter the Insurance Carrier.
Return to work and the dates unable to work
In your medical opinion, enter the date on which the patient was able to return to work, with restrictions and without restrictions.
If applicable, enter the dates when the patient was unable to work, from and to.
Future medical treatment
Do you anticipate the need for future medical treatment for this injury? Mark Yes or No.
Permanent impairment
Did the injury result in permanent impairment? Mark Yes or No. If yes, use the 6th edition of AMA Guides® to determine the impairment rating.
Injuries on or after July 1, 2014
For injuries on or after July 1, 2014, enter the percentage to the body as a whole.
Injuries prior to July 1, 2014
For injuries prior to July 1, 2014, enter the percentage to each body part and mark Left or Right.
Enter the percentage to the body part, with Left or Right.
Physician signature, date, name and license
Sign on the Physician Signature line and enter the Date.
Enter the Physician Name (Printed), the Med License # and the State.
Common questions about Form C-30A
Who signs it?
Only the treating physician completes, signs and dates this report.
Is there a deadline?
The treating physician completes this report and provides it to the adjuster or insurance carrier within 21 days of the date the injured worker has reached Maximum Medical Improvement (MMI).
Sources
[1] Form C-30A, Final Medical Report, Tennessee Bureau of Workers' Compensation (the Official source link on this page).