Parties in Tennessee workers' compensation cases file medical records with the Court of Workers' Compensation Claims, and this one-page certification lets those records come in without live testimony from the records keeper. The medical provider or the custodian of the records certifies, under Rule 0800-02-21.16(2)(b), that the attached records of a named provider are true and accurate. A Spanish version is posted with the English form.
The medical provider or the provider's records custodian checks the matching box, names the provider whose records are attached, and signs, prints a name and dates it. The case caption at the top identifies the docket, state file number and parties.
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Medical Record Certification
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Either the medical provider or the custodian of the provider's records. The form has a checkbox for each, followed by the name of the medical provider whose attached records are certified as true and accurate, and lines for the signature, printed name and date.
Yes. The Bureau's forms page lists a Spanish version, Certificación de Historial Médico, alongside the English LB-1097. Both serve the same purpose under Rule 0800-02-21.16(2)(b): certifying that attached medical records are true and accurate for filing with the Court.