Tennesse

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  Agreement Between Employer/Employee Choice of Phy

  TNWC_C-42 $39.00
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  Attending Physician Report

  NYWC_C-30 $39.00
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  C-33: Case Management Notification

  TNWC_C33 $39.00
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  C-40A: Request for Assistance

  TNWC_C40A $69.00
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  C-40B: Request for Benefit Review Conference

  TNWC_C40B $69.00
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  C-42: Employee’s Choice of Physician

  TNWC_C42 $39.00
• 

  Case Management Closure

  TNWC_C-34 $89.00
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  Case Management Notification

  TNWC_C-33 $39.00
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  Case Manager Registration

  NYWC_C-38 $39.00
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  Employer’s First Report of Work Injury

  NYWC_C-20 $89.00
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  Final Medical Report

  TNWC_C-30A $39.00
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  Final Report of Payment and Receipt of Compensation

  NYWC_C-29 $89.00
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  In-Patient Utilization Review Closure

  TNWC_C-36/37 $89.00
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  Medical Report in Lieu of Deposition

  TNWC_C-32 $179.00
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  Medical Waiver & Consent

  TNWC_C-31 $39.00
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  Monthly Report of Non-Compensable Injuries or Disease

  NYWC_C-21 $89.00