FORM 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: FORM 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. 3.
DATE OF MAXIMUM MEDICAL IMPROVEMENT _________________________. DID INJURY RESULT IN PERMANENT IMPAIRMENT? _____NO _______YES IF YES, GIVE THE FOLLOWING:
_____________ PERCENTAGE __________________ BODY PART _________ LEFT _______ RIGHT _____________ PERCENTAGE __________________ BODY PART _________ LEFT _______ RIGHT
4.
EDITION OF AMA GUIDES USED TO DETERMINE RATING ________ __________________
REPORT MUST BE DATED AND SIGNED BY THE PHYSICIAN. DATE _____________ PHYSICIAN_________________________________________________________
The copy to be filed with the Division can be provided by Fax, (615) 532-8546, or by mail, Workers' Compensation Division, 220 French Landing Drive, Nashville, TN 37243-1002.
LB0383 (REV. 01/09)
RDA 10183