Form C-34 - Case Management Closure

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FORM C-34
TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT
Division of Workers' Compensation
220 French Landing Dr.
Nashville, Tennessee 37243-1002
CASE MANAGEMENT CLOSURE
EMPLOYEE INFORMATION
State File # _______________ Date of Injury ____________ County of Injury _______________________
Claimant
_________________________________________ Social Security # _______________________
DOB
__________________ Sex
________
Occupation _______________________________
EMPLOYER INFORMATION
FEIN: ___________________ Employer: ______________________________________________________
Street: _________________________ City:
State:
Zip: __________________
INSURER INFORMATION
Insurer:
________________________________________________________________________________
Insurer Address: ____________________________________________________________________________
Insurer Claim #: ____________________________
Policy Number: _____________________________
Physician(s) Last Name
First Name
MD/DO/Chiro
License#
The reverse side of this form must be completed or all applicable diagnosis (ICD9) and procedure (CPT) codes must be
listed in the areas below.
Diagnosis: _________________________________________________________________________
___________________________________________________________________________________
Procedures: ________________________________________________________________________
___________________________________________________________________________________
Total Weeks Case Management Open __________________ Date Case Closed ___________________
Total Cost of Case Management _________________________________________________________
Medical Savings $_______________
How Saved:
___________ Negotiated provider/facility discount
____________ Arranged home PT
___________ Avoided unnecessary ER visits
____________ Prevented duplicate testing
Other ______________________________________________________________________________
___________________________________________________________________________________
Indemnity Savings $______________
How Saved:
______________ Coordinated modified duty
______________ Facilitated early RTW
______________ Assisted in making claim no lost time
Other ______________________________________________________________________________
Case Management Provider ______________________ Company # ____________________________
Case Manager(s) ______________________________ TN CM Registration #(s) _________________
_______________________________
____________________________
Closure Code _________________________________ Date of RTW __________________________
Comments:
________________________________________________________________________
-0377 (
. 12/07)
1
RDA 10183.
LB
REV

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