FORM C-33
TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT
Division of Workers' Compensation 220 French Landing Dr. Nashville, Tennessee 37243-1002
CASE MANAGEMENT NOTIFICATION
EMPLOYEE INFORMATION Social Security #_______________ State File # ______________ Date of Injury Claimant _______________________________________________________________________
EMPLOYER INFORMATION FEIN: ___________________ Employer: ______________________________________________ State: Zip: __________ Street: __________________________ City:
INSURER INFORMATION Insurer: _______________________________________________________________________ Insurer Address: ____________________________________________________________________ Insurer Claim #: ____________________________ Policy Number: _____________________
CASE MANAGEMENT ELECTION
_____ Proof of notification has been provided to employee that employer has elected to use Case Management.
PROVIDER INFORMATION
Case Management Provider _______________________________________ I.D. # ______ Case Management Provider Address ______________________________________________ ____________________________________________________ ____________________________________________________
CASE MANAGER INFORMATION
Case Management Provider Phone # ______________________________________________ Date Case Manager received referral ______________________________________________ Date Face to Face Meeting took place between CM and Employee ____________________________________________________________________________ Case Manager __________________________________ TN CM Registration # ________ Comments __________________________________________________________________ ____________________________________________________________________________
LB-0376 (REV. 09/08)
RDA 10183