Workers' comp, sports, commitment, child welfare, TennCare, WIC, retirement and public health forms from Tennessee agencies, with who completes each one.
Tennessee's clinician forms run from the Bureau of Workers' Compensation to the TSSAA, the Department of Children's Services (DCS) and the mental health department (TDMHSAS). Physicians meet the C-30A Final Medical Report at maximum medical improvement and the C-32 Standard Form Medical Report, which can stand in for a deposition. The TSSAA Preparticipation Medical Evaluation must be on file with the principal, and emergency psychiatric admissions use the MH-5542 Certificate of Need. This hub lists 30 forms, 6 of them from the Bureau.
DCS forms cover children in state custody: the CS-1097 health screening within 72 hours of entering custody, a CS-4286 Medical Report after each visit, and a CS-0629 for every psychotropic medication evaluation. The MH-5034 and MH-5032 certificates are sworn and notarized, and the MH-5032 must be executed within three days of the exam. TCRS disability retirement uses the TR-0056 Attending Physician's Report. 6 forms here have a Spanish version. Vero Documents fills PDF forms from the visit note and the chart, and the clinician reviews and signs.
C-30AAuthorized treating physician's final report at maximum medical improvement: MMI date, permanent impairment rating (AMA Guides) and permanent restrictions.
Sworn medical report on causation, treatment, impairment and restrictions that can be admitted as evidence in place of the physician's deposition.
Report of an independent Medical Impairment Rating Registry physician resolving a dispute over the permanent impairment rating (AMA Guides 5th ed. claims).
Report of a Medical Impairment Rating Registry physician's independent rating under the AMA Guides 6th edition.
LB-1097Records custodian's certification that attached medical records are true and complete, allowing their admission without live testimony.
LB-1109Physician's signed certification form used in Tennessee workers' compensation proceedings.
Attending physician documents diagnoses and body-system findings, and whether the impairment prevents past work and all other gainful employment, for TCRS ordinary or accidental disability retirement.
Physician certifies a physical disability that makes restraint by a safety belt or safety seat inappropriate (T.C.A. 55-9-603(h)).
Licensed professional's certification of a severe disability (diagnosis, onset, prognosis) supporting WeGo Access ADA paratransit eligibility in Nashville.
Physician certifies the medical necessity of an abortion (life endangerment, rape or incest exceptions) for TennCare payment.
Treating provider certifies that the standard appeal timeframe could seriously jeopardize the member's life, health or ability to regain maximum function, so a TennCare medical appeal is expedited.
Physician report on a child care provider/applicant's physical and mental fitness for approval, licensure or employment in child care.
Preparticipation medical evaluation that must be on file with the principal (TSSAA/TMSAA Bylaws Art. II, Sec. 10) stating the student passed a physical (not before April 15) and is fit to participate.
Licensed health care provider's written clearance for a student removed for a suspected concussion to return to play (Tennessee Sports Concussion Law, T.C.A. 68-55-501).
Medical release required before a student removed for signs or symptoms of sudden cardiac arrest (fainting, chest pain, etc.) may return to play under Tennessee's Sudden Cardiac Arrest Prevention Act.
Medical documentation required by 7 CFR 246.10(d) for WIC to issue exempt infant formula, WIC-eligible nutritionals or non-contract formula, and to modify WIC foods, for a participant with a qualifying medical condition.
PH-3151Referral to WIC with the provider's anthropometric and lab data (height/length, weight, hemoglobin) and nutrition-risk information, used to certify the patient for WIC.
Combined emergency detention (Part 1) and first and second Certificates of Need (Parts 2-3) for emergency involuntary admission to a hospital or treatment resource.
Examining professional's sworn certificate that a person admitted on emergency status is subject to involuntary admission, required for the probable cause hearing.
Sworn examiner certificate supporting a complaint for judicial (non-emergency) involuntary commitment; two certificates are required.
Report of suspected abuse, neglect or exploitation of a child that occurred in Tennessee.
Formulario de Informe PH-1600
Provider (and, for missing data, laboratory) report of a reportable disease or event, including STD treatment and latent TB results, to public health.
Report of suspected abuse, neglect, self-neglect or financial exploitation of a vulnerable adult.
Report of blood lead test results (including point-of-care tests) to the state lead program.
SS-3023Licensed physician states under penalty of perjury that a voter is medically unable to vote in person, placing the voter on the permanent absentee list so an absentee ballot application is sent for every election.
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
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A doctor of medicine, osteopathic physician, physician assistant or certified nurse practitioner. The evaluation must be on file with the school principal and states that the student passed a physical, done no earlier than April 15, and is fit to participate. The principal may accept a signed provider statement that covers every element of the form instead. Concussion and sudden cardiac arrest returns use separate TSSAA release forms.
Part 1, the emergency detention, can be completed by a law enforcement officer, licensed physician, psychologist with HSP designation or qualified mental health professional. Parts 2 and 3, the first and second certificates of need, are completed by an examining physician, HSP psychologist or qualified advanced practice provider. The form goes with the person to the admitting hospital and is filed with the court for the probable cause hearing. It was updated for the Title 33 amendments effective July 1, 2024.
A health screening within 72 hours of the child entering custody on the CS-1097, then a CS-4286 Medical Report for each visit, from well-child checks to dental, therapy and lab visits. Psychotropic medication evaluations go on the CS-0629, and a new medication also needs the CS-0627 informed consent attached. The CS-4286 and CS-0629 have Spanish versions. The forms go back to the caregiver or the DCS case manager.
A Secretary of State form on which a licensed physician states, under penalty of perjury, that a voter is medically unable to vote in person. It places the voter on the permanent absentee list, so an absentee ballot application is sent for every election. It is filed with the county election commission at least 10 days before the election. Voters using the ordinary ill or disabled absentee reason don't need it.