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 Improvement (MMI).

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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. FORM TO BE COMPLETED BY THE PHYSICIAN. INSURER _______________________________________ INS. CLAIM # . 1. 2.

Copy of this form to be filed with the Workers’ Compensation Carrier or Adjuster.

Final Medical Reports must be completed and filed on Form C-30A (PDF). The form requires the authorized physician to determine the date of MMI and to determine the Impairment Rating of the injury in question using the 6th Edition of the AMA Guides.

View, download and print fillable C-30a - Final Medical Report - State Of Tennessee in PDF format online. Browse 11 Tennessee Workers Compensation Forms And Templates collected for any of your needs.

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Form C-30A Final Medical Report Download Free Print-Only PDF OR Purchase Interactive PDF Version of this Form