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Tennessee Form Center -

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Form

Description

c20.pdf First Report of Work Injury
c22.pdf Notice of First Payment
c23.pdf Notice of Denial of Claim for Compensation
c26.pdf Notice of Change or Termination of Benefits
c27.pdf Notice of Controversy
c28.pdf Notice of Lawsuit
c29.pdf Final Report of Payment
c30.pdf Attending Physicians Report
c30a.pdf Final Medical Report
c31.pdf Medical Waiver and Consent
c31sp.pdf Medical Waiver and Consent (Spanish)
c32.pdf Standard Form Medical Report for Industrial Injuries
c33.pdf Case Management Notification
c34.pdf Case Management Closure
c34instructions.pdf Case Management Closure Instructions
c35.pdf Utilization Review Notification
c35a.pdf Notice of Appeal Rights for a Utilization Review Denial
c35asp.pdf Notice of Appeal Rights for a Utilization Review Denial (Spanish)
c36-37.pdf Utilization Review Closure
c36-37instructions.pdf 36-37 Form Completion Instructions
c39.pdf Provider Registration for Utilization Review
c40a.pdf Request for Mediation
c40a_sp.pdf Request for Assistance (Spanish)
c41.pdf Wage Statement
c42.pdf Agreement Between Employer / Employee Choice of Physician
c42sp.pdf Agreement Between Employer / Employee Choice of Physician (Spanish)
c42g.pdf Governemental Entities Agreement Between Employer / Employee Choice of Physician Form
c43.pdf Permanent Total Disability Final Order
c44.pdf Request for Administrative Review of a Workers' Compensation Specialist's Order
c47.pdf Medical Care and Cost Containment Committee Review Request
CMURguidelines.pdf Case Management and/or Utilization Review Guidelines
dfapp.pdf Drug-Free Workplace Program Application
FormI-1.pdf Certificate of Insurer
FormI-2.pdf Notice of Cancellation or Reinstatement of Endorsement
i-3.pdf Reduction in Workforce
i-4.pdf Sole Proprietor/Partner Election
i-5.pdf Sole Proprietor/Partner Withdrawal of Election
i-6.pdf Corporate Officer Election Not to Accept
i-7.pdf Corporate Officer Revocation of Exemption
i-8.pdf Exempt Employers Notice of Acceptance
i-9.pdf Exempt Employers Withdrawal of Notice
i-10.pdf Notice of Waiver of Workers' Compensation Benefits for Specific Medical Conditions (Combined I-10, I-11 & I-12)
i-13.pdf Waiver Withdrawal
i-14.pdf Common Carrier Election/Termination of Coverage (Combined I-14 & I-16)
i-15.pdf General Contractor Acceptance/Termination of Coverage Agreement (Combined I-15 & I-17)
c38.pdf Case Manager Registration
i-18.pdf Notice of Discontinuance of Form I-18 as of 9-07-04
MIR_appl.pdf Application for a Medical Impairment Rating
MIR_appl_registry.pdf Application for Appointment to the Medical Impairment Rating Registry
MIR_waiver.pdf MIR Medical Waiver and Consent Form
MIR_report.pdf Medical Impairment Rating Report AMA Guides 5th Edition
MIR6th_report.pdf Medical Impairment Rating Report AMA Guides 6th Edition Dates of Accident on or after 1/1/08
WC_Certificate.pdf POSTER - Tennessee Workers' Compensation Insurance Posting Notice
WC_Certificate_sp.pdf POSTER - Tennessee Workers' Compensation Insurance Posting Notice (Spanish)
wc_request_invest.pdf Request for Investigation
wc_request_invest_sp.pdf Request for Investigation (Spanish)
rsa.pdf Request for Settlement Approval
sd1.pdf Statistical Data Form
Wcbrochu1.pdf BROCHURE - A Guide to Workers' Compensation - date of accident prior to 7/1/2014
Wcbrochu2.pdf BROCHURE - A Guide to Workers' Compensation - date of accident on or after 7/1/2014
df_employer.pdf Drug Free Workplace - Employer's Program Development and Implementation Guide
DrugFreeWP_poster-1.pdf POSTER - Drug Free Workplace
LB-0476.pdf Subpoena
LB-1095.pdf Petition for Benefit Determination
LB-1095_sp.pdf Petition for Benefit Determination (Spanish)
LB-1096.pdf Dispute Certification Notice
LB-1097.pdf Medical Record Certification
LB-1098.pdf Request for Initial Hearing
LB-1099.pdf Expedited Hearing Notice of Appeal
LB-1100.pdf Request for Expedited Hearing
LB-1103.pdf Compensation Hearing Notice of Appeal