When an injured worker in Tennessee reaches maximum medical improvement (MMI), the treating physician closes out the medical side of the claim with this one-page report. It records the MMI date, when the patient could return to work with and without restrictions, any periods off work, whether future treatment is expected, and any permanent impairment rating. The adjuster or carrier uses it to close the claim with the Bureau.
Only the treating physician completes, signs and dates the report, adding a printed name, medical license number and state. No other party completes a section.
Download the current version from the source each time; forms change without notice.
Final Medical Report
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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The form says the treating physician must complete it and provide it to the adjuster or insurance carrier within 21 days of the date the injured worker reached maximum medical improvement. The MMI date is entered at the top, so the deadline runs from that date rather than from the date the form is requested.
No. The form states that it must be completed, signed and dated by the treating physician only, and it asks for the physician's printed name, medical license number and licensing state beneath the signature.