Tennessee Bureau of Workers' Compensation forms physicians complete, from the C-30A final report at MMI to the C-32 standard medical report used in court.
Tennessee's Bureau of Workers' Compensation, in the Department of Labor and Workforce Development, publishes the medical forms used on Tennessee claims. The authorized treating physician completes the Final Medical Report (C-30A) at maximum medical improvement, with the MMI date, the permanent impairment rating under the AMA Guides and permanent restrictions. The Standard Form Medical Report for Industrial Injuries (C-32) is a sworn report on causation, treatment, impairment and restrictions.
The C-30A goes to the employer or insurer, and the adjuster files it with the Bureau with the claim closing documents. A party files the C-32 with the Court of Workers' Compensation Claims, where it can stand in for the physician's deposition unless the opposing party objects. MIR Registry physicians use LB-0931 for AMA Guides 5th edition claims and LB-0931A, a Word form, for the 6th edition. The Medical Record Certification (LB-1097) also comes in Spanish.
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.
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.
Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.
The authorized treating physician completes the Final Medical Report (C-30A) and sends it to the employer or insurer. The adjuster then files it with the Bureau along with the claim closing documents. The form records the date of maximum medical improvement, the permanent impairment rating under the AMA Guides and any permanent restrictions. It is a fillable PDF, agency form number LB-0383.
The Standard Form Medical Report for Industrial Injuries. The treating or evaluating physician completes it and signs the certification. A party files it with the Court of Workers' Compensation Claims and serves it on the opposing parties. Under Tenn. Code Ann. 50-6-235(c) it can be admitted as evidence in place of the physician's deposition, but the opposing party may object and demand a deposition.
It depends on the edition of the AMA Guides. For older injuries rated under the 5th edition, the MIR Registry physician completes the Medical Impairment Rating (MIR) Report, LB-0931, a 10-page form. For 6th edition ratings, the report is the LB-0931A, a Word document. Both go back to the Bureau's MIR program, which resolves disputes over the permanent impairment rating.
The medical records custodian of the treating provider or facility signs the Medical Record Certification (LB-1097). It certifies that the attached records are true and complete, so they can be admitted without live testimony. The form is attached to medical records filed with the Court of Workers' Compensation Claims, and a Spanish version is posted on the Bureau's forms page.