Final Medical Report
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Final Medical Report Form. This is a Tennessee form and can be use in Workers Compensation.
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Tags: Final Medical Report, C-30A, Tennessee Workers Compensation,
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.
DATE OF MAXIMUM MEDICAL IMPROVEMENT _________________________.
3.
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
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