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

Online Demonstration

Confirmation of Case Management Closure

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Employee Information
SSN 123-45-6789 Date of Injury 04/01/2003
DOB 02/05/1967 Sex Male
Occupation Construction Worker County of Injury Davidson County

Medical Information
Physician(s)
Enter the overseeing physician's information.
Title License Number
Chiro 98765
First Name Last Name
Jonathan Sample
City State
Cityville Tennessee

Diagnosis Codes Description Procedure Codes Description
847.0 Cervical Strain/Sprain 847.1 Thorax Strain/Sprain
838.0 Foot Dislocation 70450 CT Head
72196 MRI Hip 71250 CT Chest
Physical Therapy? No

Case Management Information
Total weeks the Case Management was Open? 3
Date the Case was Closed? 05/05/2003
Total Cost of the Case Management? $400.34
 
Medical Savings? $500.45
How was it saved?  
Checked Negotiated provider/facility discount.
 
$600.45
How was it saved?  
Checked

Primary
Joe Manager
Secondary
Judy Sample
Tertiary
Jane Q Sample
67890
07/07/2005
 
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Online Demonstration