The Tennessee C 30A form is a crucial document used in the workers' compensation process, specifically designed for final medical reports. This form must be completed by the treating physician and includes essential details about the injured worker's condition, including return-to-work dates and any permanent impairments. To ensure compliance and avoid penalties, it is important to fill out the form accurately and submit it promptly.
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The Tennessee C 30A form plays a crucial role in the workers' compensation process, specifically as a final medical report. This document is designed to be completed by the physician who has treated the injured worker. It captures essential information such as the date of the injury, the claimant's details, and the employer's information. The form also requires the physician to indicate the return-to-work date, whether the worker is fit for regular or restricted duty, and the date of maximum medical improvement. A significant aspect of the C 30A form is its inquiry into permanent impairment resulting from the injury, which can affect the claimant's benefits. Physicians must specify the percentage of impairment and the affected body parts, using the appropriate edition of the AMA Guides to determine the rating. It is important to note that providing false or misleading information on this form can lead to serious penalties, including imprisonment and fines. The completed form must be signed and dated by the physician and submitted to the Division of Workers' Compensation, either by fax or mail, ensuring that all parties involved in the workers' compensation process have accurate and comprehensive medical information.
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
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.
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