Provider Registration For Utilization Review
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Provider Registration For Utilization Review Form. This is a Tennessee form and can be use in Workers Compensation.
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Tags: Provider Registration For Utilization Review, C-39, Tennessee Workers Compensation,
FORM C-39
TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT
Division of Workers' Compensation
220 French Landing Dr.
Nashville, Tennessee 37243-1002
PROVIDER REGISTRATION FOR UTILIZATION REVIEW
COMPANY NAME:
_____________________________________________________
COMPANY ADDRESS:
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
TELEPHONE NUMBER:
_____________________________________________________
FAX NUMBER:
_____________________________________________________
EMAIL ADDRESS:
_____________________________________________________
TN LICENSE (ASSIGNED BY COMMERCE & INSURANCE) ________________________
CREDENTIALS
DATE ISSUED
DATE EXPIRES
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
PLEASE LIST ANY PROVIDERS WITH WHOM YOU SUBCONTRACT:
_____________________________________________________________________________
_____________________________________________________________________________
SUBMITTED BY ____________________________________ TITLE ________________________
LB-0968 (REV. 03/09)
RDA 10183
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