Online Demonstration

Case Management Notification

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

Employee Information
State File Year
State File Number
Date of Injury	mm/dd/yyyy
Claimant First Name
Middle Initial
Last Name
SSN	- -
Employer Information
Enter the Employer FEIN and select the city and state.
FEIN	-
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
Case Management Election
	Proof of Notification has been provided to the employee that the employer has elected to use Case Management.
Provider Information
Case Management Provider	Provider Name
ID Number	1234
Case Management Provider Address	1234 Main Street
Address Line 2	Suite 123
City	Nashville
State	TN
Zip	37219
Phone Number	(615) 555-1234
If the information above needs to be updated, please call (615) 532-1326.
Case Manager Information
CM Provider Phone Number	(615) 555-1234
Case Manager	Jane Sample
TN CM Registration Number	987654
Date Case Manager received referral	mm/dd/yyyy
Date Face to Face Meeting took place between CM and Employee	mm/dd/yyyy
Additional Comments

Online Demonstration