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Vanderbilt Corporate Health Services - Workers' Compensation Division

Forms

Access System Satisfaction Survey

This form allows you to let us know how we are doing in meeting your needs for setting timely appointments with our panel of workers' compensation specialty physicians, and obtaining the medical records you need in a timely manner.

We appreciate any comments and suggestions.  These help us to serve you better.

Vanderbilt Workers' Compensation Access System Satisfaction Survey

Case Manager Registration Form

VUMC requires that external case managers be registered prior to access to patients to protect the privacy of our patients and to comply with HIPAA regulations.  Corporate Health Services has made arrangements with the Vanderbilt Vendor Liaison office to help us with this process.  Please link into Case Management Registration Information and Forms to learn all details of this process. 

Workers' Compensation Referral Intake Form

This form allows you to provide the necessary information online for us to set a timely appointment with the appropriate or designated specialty physician.  We will respond back to you by phone and e-mail or fax (whichever you prefer) with the confirmed appointment.

Workers' Compensation Referral Intake Form

Workers' Compensation Medical Records Request Form

This form allows you to request medical notes, return to work forms, and any other medical forms that you need that are pertinent to a particular injury.  We will fax them to you as soon as they have been entered into the system by the appropriate physician's office.

Workers' Compensation Medical Records Request Form

Customer Concern Form

This form provides an opportunity to provide feedback on your experience in the clinic dealing with waiting times, physician communication, staff courtesy and any other concerns you might have.  You can also call us anytime at 615-936-6074 with any concerns.

Customer Concern Form

* = required field

First Name *

Last Name *

Phone Number *

Phone Type

E-mail *

Designation *

Other Designation

Method of Payment *

Continuing Education *

 
 
 
 

Payment Received?

 

Attempted Call?

Notes

Amount Paid

Date Payment Received