Medical Waiver and Consent

TN State Seal

Tennessee Bureau of Workers' Compensation
220 Frence Landing Drive, 1-B
Nashville, TN 37243-1002
800-332-2667

FORM C-31

Medical Waiver and Consent

This form is not required for injuries occurring on or after July 1, 2014

THE MEDICAL AUTHORIZATION FORM ONLY PERMITS THE EMPLOYER OF THE BUREAU OF WORKERS' COMPENSATION TO OBTAIN MEDICAL INFORMATION THROUGH ORAL OR WRITTEN COMMUNICATION, INCLUDING, BUT NOT LIMITED TO, CHARTS, FILES, RECORDS, AND REPORTS IN THE POSSESSION OF A MEDICAL PROVIDER AUTHORIZED BY THE EMPLOYER PURSUANT TO T.C.A. § 50-6-204 AND A MEDICAL PROVIDER THAT IS REIMBURSED BY THE EMPLOYER FOR THE EMPLOYEE'S TREATMENT.

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I,

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Printed Patient Name
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, having filed a claim for workers' compensation benefits, do hereby authorize

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Name of Medical Provider
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to furnish to my employer or my employer's representative, and/or the Bureau of Workers' Compensation any information or written material reasonably related to my work related injury of

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Date of Injury
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for which I am claiming compensation. I further authorize the release of the same information to me or my attorney. The authorization includes, but is not restricted to, a right to review and obtain copies of all records, x-rays, x-ray reports, medical charts, prescriptions, diagnoses, opinions and courses of treatment.

A photocopy of the authorization may be accepted in lieu of the original.

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Patient Signature
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Date
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Date of Birth
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Submit