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
DOB		mm/dd/yyyy / /
Sex		Female Male
Occupation		Select Construction Worker
County of Injury		Select County Non-State County Anderson Benton Bedford Bledsoe Blount Bradley Campbell Cannon Carroll Carter Cheatham Chester Claiborne Clay Cocke Coffee Crockett Cumberland Davidson Decatur DeKalb Dickson Dyer Fayette Fentress Franklin Gibson Giles Grainger Greene Grundy Hamblen Hamilton Hancock Hardeman Hardin Hawkins Haywood Henderson Henry Houston Humphreys Jackson Jefferson Johnson Knox Lake Lauderdale Lawrence Lewis Lincoln Loudon Macon Madison Marion Marshall Maury McMinn McNairy Meigs Monroe Montgomery Moore Morgan Obion Overton Perry Pickett Polk Putnam Rhea Roane Robertson Rutherford Scott Sequatchie Sevier Shelby Smith Stewart Sullivan Sumner Tipton Trousdale Unicoi Union Van Buren Warren Washington Wayne Weakley White Williamson Wilson
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.
Title		License Number
Select MD DO Chiro DDS Other Out of State
First Name		Last Name
City		State
		Tennessee Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Virgin Islands Washington West Virginia Wisconsin Wyoming

ICD Code		Select ICD 9 ICD 10
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.
Diagnosis Code(s)
Procedure Code(s)
Physical Therapy?	Yes No
Case Management Information
Total weeks the Case Management was Open?
Date the Case was Closed?		mm/dd/yyyy
Total Cost of the Case Management?		(include dollars and cents) $ .
Medical Savings?		(include dollars and cents) $ .
How was it saved?
	Negotiated provider/facility discount.
	Arranged home PT.
	Avoided unnecessary ER visits.
	Prevented duplicate testing.
	Other.
	If other, explain
Indemnity Savings?		(include dollars and cents) $ .
How was it saved?
	Coordinated modified duty.
	Facilitated early RTW.
	Assisted in making claim no lost time.
	Other.
	If other, explain
Case Manager(s)	Primary Joe Manager
Secondary Registration Number
Tertiary Registration Number
Closure Code		Select
Return To Work (RTW) Date		mm/dd/yyyy
Additional Comments

Online Demonstration