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 120 State Forms found

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NOTICE OF WITHDRAWAL (Spanish)

 FORMULARIO I-5 / LB-0287s (REV 11/15)

NOTICE OF ACCEPTANCE OF THE "TENNESSEE WORKERS' COMPENSATION ACT" BY AN EXEMPTED EMPLOYER (Spanish)

 FORMULARIO I-8 / LB-0014s (REV. 4/18)

NOTICE OF WITHDRAWAL OF AN EXEMPT EMPLOYERS’ VOLUNTARY ELECTION (Spanish)

 FORMULARIO I-9 / LB-0289s (REV 11/15)

NOTICE OF WAIVER OF WORKERS’ COMPENSATION BENEFITS FOR SPECIFIC MEDICAL CONDITIONS (Spanish)

 LB-0290s / FORMULARIO COMBINADO I-10, I-11, I-12 (REV 11/15)

LEASED OPERATOR OR OWNER OPERATOR ELECTION/TERMINATION OF COVERAGE (Spanish)

 FORMULARIO COMBINADO I-14 Y I-16 / LB-0300s REV 11/15

GENERAL CONTRACTOR ACCEPTANCE/TERMINATION OF COVERAGE AGREEMENT (Spanish)

 FORMULARIO COMBINADO I-15 Y I-17 / LB-0301s (REV 11/15)

DISPUTE CERTIFICATION NOTICE (Spanish)

 LB-1096 / RDA 10183 Rev. 3/16

REQUEST FOR MEDIATION (Spanish)

 LB-0381s Rev. 8/2021

PETITION FOR BENEFIT DETERMINATION (Spanish)

 LB-1095s Rev. 09/23

CERTIFICATE OF NON-REPRESENTATION (CNR)

 LB-3252 /RDA-10183 08-2017

CERTIFICATE OF NON-REPRESENTATION (CNR) (Spanish)

 LB-3252 / RDA-10183 08-2017

NOTICE OF APPEAL RIGHTS FOR A UTILIZATION REVIEW DENIAL (Spanish)

 LB-1023s / FORMULARIO C-35A (REV 12/16)

REQUEST TO MIR PROGRAM FOR A MEDICAL IMPAIRMENT RATING (Spanish)

 LB-0930s (REV 11/15)

MEDICAL IMPAIRMENT RATING (MIR) MEDICAL WAIVER AND CONSENT (Spanish)

LB-0929s Se modificó en 9/16

REQUEST FOR EXPEDITED DETERMINATION-APPEAL OF A DENIED PRESCRIPTION

 LB-1123 (REV 8/16)
Disclaimer: These forms may not be the most recent version. Tennessee may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on this site. Please check official sources.
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