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 20 State Forms found

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FINAL MEDICAL REPORT

 FORM C-30A / LB-0383 (REV 1/17)

EMPLOYEE’S CHOICE OF PHYSICIAN

 Form C-42 / LB-0382 (REV 03/2025)

EMPLOYEE’S CHOICE OF PHYSICIAN (Spanish)

 FORMULARIO C-42 / LB-0382 (REV 3/25)

REQUEST TO MIR PROGRAM FOR A MEDICAL IMPAIRMENT RATING

 LB-0930 (REV 1/18)

CASE MANAGEMENT CLOSURE

 Form C-34 / LB-0377 (REV. 05/23)

NOTICE OF WAIVER OF WORKERS’ COMPENSATION BENEFITS FOR SPECIFIC MEDICAL CONDITIONS

 LB-0030 / COMBINED FORM I-10, FORM I-11, FORM I-12 (REV 11/15)

MEDICAL PAYMENT COMMITTEE REVIEW REQUEST

 FORM C-47 / LB-1017 (REV 11/24)

MEDICAL IMPAIRMENT RATING (MIR) MEDICAL WAIVER AND CONSENT

 LB-0929 (REV 9/16)

MEDICAL IMPAIRMENT RATING (MIR) REPORTAMA GUIDES™, 5TH EDITION

 LB-0931 (REV 11/15)

MEDICAL IMPAIRMENT RATING (MIR) REPORT AMA GUIDES™, 6TH EDITION

 LB-0931A (rev 01/20)

STANDARD FORM MEDICAL REPORT FOR INDUSTRIAL INJURIES

 Form C-32 / LB-0369 (REV 11/17)

MEDICAL WAIVER AND CONSENT

 FORM C-31 / LB-0379 (REV 11/15)

MEDICAL WAIVER AND CONSENT (Spanish)

 FORMULARIO C-31/LB-0379s (REV 11/15)

MEDICAL RECORD CERTIFICATION

 LB-1097 rev. 8/19

PHYSICIAN CERTIFICATION FORM

 LB-1109 (REV 11/15)
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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