Form LB-0379 (C-31) "Medical Waiver and Consent" - Tennessee

Form LB-0379 (C-31) Printable Pdf
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What Is Form LB-0379 (C-31)?

This is a legal form that was released by the Tennessee Department of Labor and Workforce Development - a government authority operating within Tennessee. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on November 1, 2015;
  • The latest edition provided by the Tennessee Department of Labor and Workforce Development;
  • Easy to use and ready to print;
  • Available in Spanish;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form LB-0379 (C-31) by clicking the link below or browse more documents and templates provided by the Tennessee Department of Labor and Workforce Development.

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Download Form LB-0379 (C-31) "Medical Waiver and Consent" - Tennessee

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Tennessee Bureau of Workers’ Compensation
220 French Landing Drive, I-B
Nashville, TN 37243-1002
800-332-2667
FORM C-31
MEDICAL WAIVER AND CONSENT
This form is not required for injuries occurring on or after July 1, 2014
THIS MEDICAL AUTHORIZATION FORM ONLY PERMITS THE EMPLOYER OR THE BUREAU OF WORKERS’
COMPENSATION TO OBTAIN MEDICAL INFORMATION THROUGH ORAL OR WRITTEN COMMUNICATION,
INCLUDING, BUT NOT LIMITED TO, CHARTS, FILES, RECORDS, AND REPORTS IN THE POSSESSION OF A
MEDICAL PROVIDER AUTHORIZED BY THE EMPLOYER PURSUANT TO T.C.A. § 50-6-204 AND A MEDICAL
PROVIDER THAT IS REIMBURSED BY THE EMPLOYER FOR THE EMPLOYEE’S TREATMENT.
I, ______________________________, having filed a claim for workers' compensation benefits, do hereby authorize
(Printed Patient Name)
______________________________________________________ to furnish to my employer or my employer’s
(Name of Medical Provider)
representative, and/or the Bureau of Workers' Compensation any information or written material reasonably related to my
work-related injury of _____________________for which I am claiming compensation. I further authorize the release of
(Date of Injury)
the same information to me or my attorney. The authorization includes, but is not restricted to, a right to review and obtain
copies of all records, x-rays, x-ray reports, medical charts, prescriptions, diagnoses, opinions and courses of treatment.
A photocopy of the authorization may be accepted in lieu of the original.
__________________________________________________________________________________________________
Patient Signature
Date
Date of Birth
LB-0379 (REV 11/15)
RDA 10183
Tennessee Bureau of Workers’ Compensation
220 French Landing Drive, I-B
Nashville, TN 37243-1002
800-332-2667
FORM C-31
MEDICAL WAIVER AND CONSENT
This form is not required for injuries occurring on or after July 1, 2014
THIS MEDICAL AUTHORIZATION FORM ONLY PERMITS THE EMPLOYER OR THE BUREAU OF WORKERS’
COMPENSATION TO OBTAIN MEDICAL INFORMATION THROUGH ORAL OR WRITTEN COMMUNICATION,
INCLUDING, BUT NOT LIMITED TO, CHARTS, FILES, RECORDS, AND REPORTS IN THE POSSESSION OF A
MEDICAL PROVIDER AUTHORIZED BY THE EMPLOYER PURSUANT TO T.C.A. § 50-6-204 AND A MEDICAL
PROVIDER THAT IS REIMBURSED BY THE EMPLOYER FOR THE EMPLOYEE’S TREATMENT.
I, ______________________________, having filed a claim for workers' compensation benefits, do hereby authorize
(Printed Patient Name)
______________________________________________________ to furnish to my employer or my employer’s
(Name of Medical Provider)
representative, and/or the Bureau of Workers' Compensation any information or written material reasonably related to my
work-related injury of _____________________for which I am claiming compensation. I further authorize the release of
(Date of Injury)
the same information to me or my attorney. The authorization includes, but is not restricted to, a right to review and obtain
copies of all records, x-rays, x-ray reports, medical charts, prescriptions, diagnoses, opinions and courses of treatment.
A photocopy of the authorization may be accepted in lieu of the original.
__________________________________________________________________________________________________
Patient Signature
Date
Date of Birth
LB-0379 (REV 11/15)
RDA 10183
Tennessee Department of Labor and Workforce Development Tennessee Legal Forms United States Legal Forms

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