State of Tennessee Forms in Microsoft Word

c22

Notice of First Payment

c23

Notice of Denial of Claim for Compensation

c26

Notice of Change or Termination of Benefits

c27

Notice of Controversy

c28

Notice of Lawsuit

c29

Final Report of Payment

c30

Attending Physicians Report

c30a

Final Medical Report

c31

Medical Waiver and Consent

c31s

Medical Waiver and Consent SPANISH

c32

Medical Report in Lieu of Deposition

c33

Case Management Notification

c34

Case Management Closure

c35

Utilization Review Notification

c35a

Notice Of Appeal Rights For A Utilization Review Denial

c36-37

Utilization Review Closure

c38

Case Manager Registration

c39

Provider Registration for Utilization Review

c40a

Request for Assistance

c40b

Request for Benefit Review Conference

c40r

Benefit Review Conference Certificate of Readiness

c41

Wage Statement

c42

Agreement Between Employer/Employee Choice Of Physician

c42sp

La ELECCION del EMPLEADO DE MEDICO

c42g

Agreement Between Employer/Employee Choice Of Physician Form 3/04

c43

Permanent Total Disability Final Order

c44

Request for Administrative Review of a Workers’ Compensation Specialist’s Order

c47

Medical Care Cost Containment Committee Review Request

CMURguidelines

Case Management And/Or Utilization Review Guidelines

i-3

Reduction in Workforce

i-4

Sole Proprietor/Partner Election

i-5

Sole Proprietor/Partner Withdrawal of Election

i-6

Corporate Officer Election Not to Accept

i-7

Corporate Officer Withdrawal of Election Not to Accept

i-8

Exempt Employers Notice of Acceptance

i-9

Exempt Employers Withdrawal of Notice of Acceptance

i-10

Heart Waiver of Notice of Acceptance

i-11

Occupational Disease Waiver

i-12

Epilepsy Waiver

i-13

Waiver Withdrawal

i-14

Leased Operator/Common Carrier Election

i-15

Subcontractor/General Contractor Election

i-16

Leased Operator/Common Carrier Withdrawal of Election

i-17

Subcontractor/General Contractor Withdrawal of Election

sd1

Statistical Data Form

CMURguidlines

Case Management and Utilization Review Form Guidelines

MIR appl

Application for Medical Impairment Rating

MIR appl registry

Application for MIR Appointment

MIR waiver

MIR Medical Waiver and Consent Form

MIR report

MIR Impairment Rating Report 5th Edition 4/09

MIR6th report

Medical Impairment Rating MIR

dfapp

Drug-Free Workplace Premium Credit Program Application Form

rsa

Request for Settlement Approval

sd1

Workers Compensation Statistical Data Form

wc request invest

Request For Investigation

wc request invest sp

Request For Investigation Spanish

df employer

Drug Free Workplace Employer’s Program Development and Implementation Guide