Online Demonstration

Confirmation of Case Management Notification

Thank You. Your Case Management Notification was successfully submitted on .

You will receive a copy of this confirmation page shortly to; you@somewhere.something, the e-mail address you provided when you logged in. Please print this page for your records.

Employee Information
State File Year	2003	State File Number	123456
Date of Injury	02/03/2002	Claimant Name	Joe Q Sample
SSN	111-11-1111
Employer Information
FEIN	12-3456789	Employer	Sample Employer Inc.
Address Line 1	1111 Main St.	Address Line 2	Suite 1
City	Cityville	State	TN
Zip	11111
Medical Information
Insurer	Sample Insurer Inc.
Insurer Claim Number	98765	Policy Number	12345
Case Management Election
Checked	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		12345
Case Management Provider Address Line 1	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
Date Case Manager received referral		04/03/2002
Date Face to Face Meeting took place between CM and Employee		06/06/2002
Case Manager	Jane Sample	TN CM Registration Number	987654

Online Demonstration