Tennessee Form C 30A PDF Details

Are you a business in Tennessee that is having trouble figuring out all the ins and outs of filing your very important Form C-30A? Filing this form accurately and on time is critical for many businesses, so it pays to understand the process, know what information you need, and have access to relevant resources. Fortunately, we can help explain everything you need to know about filling out and submitting Tennessee Form C 30A. Understanding the requirements set forth by the state’s Department of Revenue will ensure accuracy in your filings—saving valuable time and money down the line!

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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