Tennessee Department of Labor and Workforce Development Division of Workers' Compensation.

Online Demonstration

Case Management Closure

Please complete the form to submit a Case Management Closure. Click on "Next" at the bottom of this page to continue on.

Employee Information
SSN 123-45-6789 Date of Injury 04/01/2003
  mm/dd/yyyy
/ /
Female Male

Medical Information
Physician(s)
Select the Title and enter the License Number of the Physician.
If you select "Other", "Out-of-state", or "DDS" from the drop down, you must enter the First and Last Name, City, and State of the overseeing physician.



Please enter in the Diagnosis and Procedure codes into the boxes provided. Click on the words 'Diagnosis Code(s)' and 'Procedure Code(s)' to get a list of common codes used.
         
         
         
         
Yes No

Case Management Information
  Click here to Date Stamp.  mm/dd/yyyy
 (include dollars and cents)
$ .
 
 (include dollars and cents)
$ .
How was it saved?  
 
 
 (include dollars and cents)
$ .
How was it saved?  
 

Primary
Joe Manager
  Click here to Date Stamp.  mm/dd/yyyy
 
Next.

 

Online Demonstration