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Form C 35autilization Review Denial Appeal Tngov

Q: What is the Form C 35a Utilization Review Denial Appeal TN gov process?

The Form C 35a Utilization Review Denial Appeal TN gov process allows individuals to appeal a denial from a utilization review. This form is essential for ensuring that your appeals are submitted correctly and in a timely manner, following state regulations. Using airSlate SignNow can simplify this process, allowing you to eSign and submit your appeal documents efficiently.

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LB -102 3 (12/16 ) RD A 10183 FORM C-33 TENNESSEE BUREAU OF WORKERS ’ COMPENSATION 220 French Landing Dr., 1B Nashville, Tennessee 37243 -1002 Website: www.tn.gov/workforce/section/injuries- at-work CASE MANAGEMENT NOTIFICATION EMPLOYEE INFORMATION State File # Date of Injury Social Security # Clai mant EMPLOYER INFORMATION FEIN: Em ployer : Street: Cit y: State: Zip : INSURER INFORMATION Insurer: Insurer Address: Insurer Claim #: Policy Nu mb er: CASE MANAGEMENT ELECTION Proof of notification has been provided to employee that employer has elected to use Case Manage ment. PROVIDER INFORMATION Case Management Provider I.D. # Case Manage ment Provider Address CASE MANAGER INFORMATION Case Management Provider Phone # Date Case Manager received referral Date Face to Face Meeting took place between CM and Employee Case Manager Co mm ents TN CM Registration #

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