LB-1023 (/1) INSTRUCTIONS RDA 10183 FORM C-35A TENNESSEE BUREAU OF WORKERS222 COMPENSATION 220 French Landing Dr., 1B Nashville, Tennessee 37243-1002 Website: www.tn.gov/workforce/section/injuries-at-work NOTICE OF APPEAL RIGHTS FOR A UTILIZATION REVIEW DENIAL 1. The adjuster must complete this page, attach it and to theemployee and the treating physician with each denial. 2. Failure by the adjuster to accurately complete this form and provide it timely in its claimant may result in a penalty referral. INITIAL UTILIZATION REVIEW UR Agent: UR State Registration No.: Denied Treatment: EMPLOYER Employee Name: Company Name: State File No.: Address: Injury Date: City/State/Zip: SSN: Phone: Fax: Address: Email: City/State/Zip: CARRIER Phone: Fax: Carrier Name: Email: Adjuster Name: AUTHORIZED TREATING PHYSICAN Address: Name: City/State/Zip: Address: Phone: Fax: City/State/Zip: Email: Phone: Fax: Claim No.: Email: Carrier222s ComplianceEmail: EMPLOYEE ATTORNEY (if applicable) EMPLOYER/CARRIER ATTORNEY (if applicable) Name: Name: Address: Address: City/State/Zip: City/State/Zip: Phone: Fax: Phone: Fax: Email: Email: Printed Name of Person Submitting Request: EMPLOYE American LegalNet, Inc. www.FormsWorkFlow.com LB-1023 (/1) RDA 10183 FORM C-35A TENNESSEE BUREAU OF WORKERS222 COMPENSATION 220 French Landing Dr., 1B Nashville, Tennessee 37243-1002 Website: www.tn.gov/workforce/section/injuries-at-work NOTICE OF APPEAL RIGHTS FOR A UTILIZATION REVIEW DENIAL Instructions for Appealing Employees have the right to appeal the denial of recommended medical treatment. If you disagree with the denial of your recommended medical treatment by the Utilization Review Agent, then you as an employee, your attorney or your treating physician can request the Bureau of Workers222 Compensation to review the facts of your case and to issue a decision. The review will be performed at no cost to you. To request such a review, you must: 1.Print your name and contact information on the attached FORM C-35A and submit the completedform 223Notice of Appeal Rights for a Utilization Review Denial224; (Here Attached.) 2.Provide a copy of the Utilization Review Decision and Peer Reviewer's Report; 3.Provide a copy of all medical records over the past twelve (12) months pertaining to the workers222compensation injury, including office visits, diagnostic reports, operative notes, physical therapynotes, and hospital visits; 4.Provide a copy of any medical release that you have signed for the authorized treating physician or asigned 223Medical Waiver and Consent,224 available on the Bureau222s website; and, 5.Submit all of the above within thirty (30) calendar days of receiving your Utilization Review ReportDenial to the Tennessee Bureau of Workers222 Compensation. You may submit them:a.by fax to (615) 253-5265;b.by email to UR.appeals@tn.gov ; or, c.by mail to Tennessee Bureau of Workers222 Compensation ATTN: Medical Director 220 French Landing Drive., 1B Nashville, TN 37243-1002 If the completed FORM C-35A and requested documents from line 2 above are not received by the Bureau of Workers222 Compensation within the thirty (30) calendar days you may lose your right to appeal. If you have any questions or need assistance in completing this form, call 1-800-332-2667 or 615-741-4361. American LegalNet, Inc. www.FormsWorkFlow.com