Program Area |
Name |
Form Number |
Spanish Equivalent |
---|
Appeals Board
|
Affidavit of Indigency |
LB-1108
LB-1108s |
Declaración Jurada sobre Indigencia |
Claims
|
Agreement Between Employer/Employee Choice of Physician |
C-42
LB-0382s |
Selección de Médico por un Empleado |
Claims
|
Agreement Between Employer/Employee Choice of Physician - Government |
C-42 |
N/A |
Medical |
Application for Exemption from Electronic Medical Billing Requirements |
None |
N/A |
Claims |
First Report of Injury |
C-20 LB-0021 |
N/A |
Claims |
Notice of Change or Termination of Benefits |
C-26 LB-0285 |
N/A |
Claims |
Notice of Controversy |
C-27 |
N/A |
Claims |
Notice of Denial of Claim for Compensation |
C-23 |
N/A |
Compliance
|
Employee MIsclassification Tip |
LB-0977s |
Formulario de Informaci'on de Clasificaión Indebida del Empleado |
Compliance |
Request for Investigation |
LB-0977
LB-0977s |
Petición para Investigación |
Court of Workers’ Compensation Claims
|
Compensation Hearing Notice of Appeal |
LB-1103 |
N/A
|
Court of Workers’ Compensation Claims
|
Expedited Hearing Notice of Appeal |
LB-1099 |
N/A
|
Court of Workers’ Compensation Claims
|
Medical Record Certification |
LB-1097 |
N/A
|
Court of Workers’ Compensation Claims
|
Request for Expedited Hearing |
LB-1100 |
N/A
|
Court of Workers’ Compensation Claims
|
Request for Scheduling Hearing |
LB-1098Request for Initial Hearing |
N/A
|
Court of Workers’ Compensation Claims
|
Standard Form Medical Report |
C-32 |
N/A
|
Court of Workers’ Compensation Claims
|
Subpoena |
LB-0476
|
N/A
|
Court of Workers’ Compensation Claims
|
Petition for Benefits Determination - Settlement Only |
LB-1120 |
N/A |
Coverage
|
Certificate of Insurer Form I-1 |
LB-0043 |
N/A |
Coverage
|
Notice of Cancelation Form I-2 |
LB-0004 |
N/A |
Coverage
|
Reduction in Workforce Form I-3 |
LB-0286 |
N/A |
Coverage
|
Sole Proprietor/Partner Selection Form I-4 |
LB-0228
LB-0228s |
Aviso de Elección |
Coverage
|
Sole Proprietor/Partner Withdrawal of Election Form I-5 |
LB-0287
LB-0287s |
Aviso de Retiro |
Coverage
|
Corporate Officer Election Not To Accept Form I-6 |
LB-0090 |
N/A |
Coverage
|
Corporate Officer Withdrawal of Election Form I-7 |
LB-0288 |
N/A |
Coverage
|
Exempt Employer Notice of Acceptance Form I-8 |
LB-0014
LB-0014s |
Aviso de Aceptación |
Coverage
|
Exempt Employer Withdrawal of Notice Form I-9 |
LB-0289
LB-0289s |
Aviso de Retiro de Elección Voluntaria de Empleador Exento |
Coverage
|
Notice of Waiver of Workers' Compensation Benefits for Specific Medical Conditions I-10 |
LB-0030
LB-0290s |
Aviso de Exención |
Coverage
|
Waiver Withdrawal Form I-13 |
LB-0290 |
N/A |
Coverage
|
Common Carrier Election / Termination of Coverage Form I-14 |
LB-0300
LB-0300s |
Selección de Compañía Común/Terminación de Cobertura |
Coverage
|
Combined Form I-15 & I-17 General Contractor Acceptance / Termination of Coverage Agreement |
LB-0301
LB-0301s |
Aceptación de Contratista General |
Coverage
|
Notice of Discontinuance Form I-18 |
N/A |
N/A |
Coverage
|
Posting Notice |
LB-0922
LB-0922SP |
Aviso de Seguro de Compensación de Trabajadores de Tennessee |
Mediation
|
Dispute Certification Notice |
LB-1096 |
Aviso de Certificación de Disputa |
Mediation
|
Request for Assistance Form / Mediation Form |
C-40
LB-0381
LB-0381s |
Solicitud para Mediación |
Mediation
|
Wage Statement Form |
C-41
LB-0384 |
N/A |
Mediation
|
Permanent Total Disability Final Order Form |
C-43
LB- 0988 |
N/A |
Mediation
|
Request for Administrative Review of a WC Specialist's Order Form |
C-44
LB-1016 |
N/A |
Mediation
|
Petition for Benefits Determination |
LB 1095
LB-0381s |
Petición para Determinación de Beneficios |
Mediation
|
Certificate of Non-Representation (CNR) |
LB-3252 |
Certificado de No Representación (CNR) |
Medical
|
Drug Free Workplace Program Application |
LB-1111
LB-0977 |
Solicitud del Programa para Ambiente Laboral Libre de Drogas |
Medical
|
Medical Waiver and Consent Form |
C-31
LB-0379
LB-0379s |
Consentimiento y Exención Médica |
Medical
|
Case Management Notification |
C-33
LB-1023 |
N/A |
Medical
|
Case Management Instructions |
C-34 |
N/A |
Medical
|
Case Management Closure |
C-34
LB-0377 |
N/A |
Medical
|
Utilization Review Notification Form |
C-35
LB-0380 |
N/A |
Medical
|
Notice of Appeal Rights for a Utilization Review Denial |
C-35A
LB-1023s |
Aviso de derechos de apelación para una Revisión de Utilización |
Medical
|
Utilization Review Closure Form |
C-36 | C-37
LB-0375 |
N/A |
Medical
|
Case Management Registration Form |
C-38
LB-0965 |
N/A |
Medical
|
Provider Registration for Utilization Review Form |
C-39
LB-0968 |
N/A |
Medical
|
Medical Payment Committee Review Request Form |
C-47
LB-1017 |
N/A |
Medical
|
MIR Application for a Medical Impairment Rating |
LB-0930
LB-0930s |
Solicitud al Progama MIR para una Clasificación de Discapacidad Médica |
Medical
|
MIR Application for Appointment to the Medical Impairment Rating Registry |
LB-0928 |
N/A |
Medical
|
MIR Impairment Rating Report - 5th Edition |
LB-0931 |
N/A |
Medical
|
MIR Impairment Rating Report - 6th Edition |
LB-0931A |
N/A |
Medical
|
MIR Medical Waiver and Consent Form |
LB-0929
LB-0929s |
Denuncia y Consentimiento de Calificación de Discapacidad Médica |
Medical
|
Final Medical Report Form |
C-30A
LB-0383 |
N/A |
Medical
|
Physician Certification |
LB-1109 |
N/A |
Medical
|
Request for Expedited Determination - Appeal of a Denied Prescription |
LB-1123 |
N/A |
Settlement Approval
|
Request for Settlement Approval |
LB-0932 |
N/A |
Settlement Approval
|
SD-1 Statistical Data Form |
LB-0904 |
N/A |