This short Tennessee form lets a physician certify, under Tennessee Code section 50-6-242(a)(2)(B), that permanent restrictions caused by a work injury leave the employee unable to perform the pre-injury occupation. It applies only to injuries on or after July 1, 2014. The Bureau lists it among the forms used in the Court of Workers' Compensation Claims.
The physician completes and signs the certification with a printed name, medical license number and issuing state. The patient's name, date of birth, state file number, date of injury and date of MMI are entered at the top.
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Physician Certification
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That due to permanent restrictions on activity resulting from the work injury, the employee no longer has the ability to perform the employee's pre-injury occupation. It is made under T.C.A. 50-6-242(a)(2)(B) and is signed by the physician with a license number and issuing state.
No. The form states that it is only to be used for injuries occurring on or after July 1, 2014, the same date that divides other Tennessee forms, such as the C-30A and C-32, into separate rules for older injuries.