Case Manager Registration
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Case Manager Registration Form. This is a Tennessee form and can be use in Workers Compensation.
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Tags: Case Manager Registration, C-38, Tennessee Workers Compensation,
FORM C-38
TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT
Division of Workers' Compensation
220 French Landing Dr.
Nashville, Tennessee 37243-1002
CASE MANAGER REGISTRATION
NAME: ______________________________________________________________________
TITLE: ______________________________________________________________________
CERTIFICATIONS:
TYPE
CERTIFICATION NUMBER
DATE ISSUED
DATE EXPIRES
1.
2.
3.
R.N. LICENSE NUMBER: _________________ DATE OF EXPIRATION: _________________
M.D. LICENSE NUMBER: _________________ DATE OF EXPIRATION: ________________
STATE ISSUING LICENSE: __________ TEMPORARY__________ PERMANEMT________
IN ORDER TO PROCESS YOUR REGISTRATION, COPIES OF YOUR CURRENT R.N. OR M.D.
LICENSE AND/OR CERTIFICATIONS MUST BE SUBMITTED WITH COMPLETED FORM.
COMPANY NAME: ____________________________________________________________
COMPANY ADDRESS: ________________________________________________________
________________________________________________________
________________________________________________________
COMPANY TELEPHONE NUMBER:
(
) ____________________________
YOUR OFFICE PHONE NUMBER:
(
) ____________________________
FAX NUMBER:
(
) ____________________________
EMAIL ADDRESS: ___________________________________________________________
PLEASE LIST ANY PROVIDERS WITH WHOM YOU SELF CONTRACT:
_____________________________________________________________________________
SIGNATURE: ________________________________________________________________
LB-0965 (REV. 10/11)
RDA 10183
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