Fill and Sign the Final Medical Report Form

LB-0383 (REV 1 /17) RDA 10183 Tennessee Bureau of Workers’ Compensation 220 French Landing Drive, I-B Nashville, TN 37243-1002 800-332-2667 FORM C-30A FINAL MEDICAL REPORT This Report is to be completed by the treating physician and provided to the adjuster or insurance carrier within 21 days of the date the injured worker has reached Maximum Medical Improve ment (MMI). STATE FILE # __________________ DATE OF INJURY __________________ DATE OF MMI _________________ PATIENT NAME __________________________________________ SSN ____________________________________ EMPLOYER ______________________________________________________________________________________ INSURANCE CARRIER _______________________________________________________________ ______________ IN YOUR MEDICAL OPINION , ON WHAT DATE WAS THE PATIENT ABLE TO RETURN TO WORK, WITH RESTRICTIONS? ______________________ WITHOUT RESTRICTIONS? _____________________ IF APPLICABLE, WHAT WERE THE DATES WHEN THE PATIENT WAS UNABLE TO WORK? FROM____________ TO______________ DO YOU ANTICIPATE THE NEED FOR FUTURE MEDICAL TREATMENT FOR THIS INJURY? YES NO DID THE INJURY RESULT IN PERMANENT IMPAIRMENT? YES NO IF YES, COMPLETE THE FOLLOWING: (USE THE 6th EDITION OF AMA GUIDES® TO DETERMINE THE IMPAIRMENT RATING) FOR INJURIES ON OR AFTER JULY 1, 2014 ____________ PERCENTAGE TO THE BODY AS A WHOLE FOR INJURIES PRIOR TO JULY 1, 2014 ______________ PERCENTAGE to __________________________ ____________________ BODY PART LEFT RIGHT ______________ PERCENTAGE to ______________________________ ________________ BODY PART LEFT RIGHT ______________ PERCENTAGE to ______________________________ ________________ BODY PART LEFT RIGHT This Report must be completed, signed and dated by the treating physic ian only. PHYSICIAN SIGNATURE____________________________________________ DATE_________________________ PHYSICIAN NAME (Printed) ______________________________ MED LICENSE # _____________STATE ______