Form C-30a - Final Medical Report - State Of Tennessee
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1FORM 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:
REPORT 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: FOR INJURIES ON OR AFTER JULY 1, 2014, THE TREATING
PHYSICIAN OR CHIROPRACTOR SHALL ASSIGN IMPAIRMENT RATINGS AS A PERCENTAGE
OF THE BODY AS A WHOLE. FOR INJURIES PRIOR TO JULY 1, 2014, THE RATING CAN BE
TO INDIVIDUAL BODY PARTS.
_____________ PERCENTAGE __________________ BODY PART _________ LEFT _______ RIGHT
_____________ PERCENTAGE __________________ BODY PART _________ LEFT _______ RIGHT
_____________ PERCENTAGE __________________ TO THE BODY AS A WHOLE
4.
EDITION OF AMA GUIDES USED TO DETERMINE RATING ________ __________________
REPORT MUST BE DATED AND SIGNED BY THE PHYSICIAN.
PHYSICIAN NAME (Please Print or Type) ___________________________________________________
PHYSICIAN SIGNATURE _______________________________________ DATE ___________________
Copy of this form to be filed with the Workers’ Compensation Carrier or Adjuster.
10183
LB0383 (
. 07/14)
RDA
REV
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