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: REPORT 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: FOR INJURIES ON OR AFTER JULY 1, 2014, THE TREATING PHYSICIAN OR CHIROPRACTOR SHALL ASSIGN IMPAIRMENT RATINGS AS A PERCENTAGE OF THE BODY AS A WHOLE. FOR INJURIES PRIOR TO JULY 1, 2014, THE RATING CAN BE TO INDIVIDUAL BODY PARTS. _____________ PERCENTAGE __________________ BODY PART _________ LEFT _______ RIGHT _____________ PERCENTAGE __________________ BODY PART _________ LEFT _______ RIGHT _____________ PERCENTAGE __________________ TO THE BODY AS A WHOLE 4. EDITION OF AMA GUIDES USED TO DETERMINE RATING ________ __________________ REPORT MUST BE DATED AND SIGNED BY THE PHYSICIAN. PHYSICIAN NAME (Please Print or Type) ___________________________________________________ PHYSICIAN SIGNATURE _______________________________________ DATE ___________________ Copy of this form to be filed with the Workers' Compensation Carrier or Adjuster. LB0383 (REV. 07/14) RDA 10183 American LegalNet, Inc. www.FormsWorkFlow.com