STATE OF TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT Workers’ Compensation Division Medical Impairment Rating Program Andrew Johnson Tower 710 James Robertson Parkway, 2nd Floor Nashville, TN 37243-0655 (615) 253-1613 (615) 253-5263 fax Medical Impairment Rating (MIR) Impairment Rating Report A. PATIENT INFORMATION (please type or neatly print all responses) Claimant Name ____________________________________________________________________________ Address ___________________________________________________________________________________ City, State, Zip ______________________________________________ Phone # _______________________ State File # __________________________________ MIR case # ____________________________________ Social security # _____________________________ Date of Birth ___________________________________ Date of Injury ____________________________ Date of MIR Evaluation ____________________________ B. MIR PHYSICIAN INFORMATION MIR Physician Name _______________________________________________________________________ Address __________________________________________________________________________________ City, State, Zip _____________________________________________ Phone #________________________ Location of evaluation if different than above) __________________________________________________ __________________________________________________________________________________________ LB-0931 RDA 10183 1 American LegalNet, Inc. www.USCourtForms.com C. PATIENT HISTORY INTRODUCTION AND OVERVIEW (brief description of the injury/illness, prior treatment received, and periods claimant was unable to work) __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ 2 American LegalNet, Inc. www.USCourtForms.com D. PHYSICAL EXAMINATION __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ _________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ 3 American LegalNet, Inc. www.USCourtForms.com E. Name & Address of All treatment Providers CLAIMANT’S CHRONOLOGICAL MEDICAL HISTORY Date Treatment Received Nature of the injury or illness? Part of the body affected? Make additional copies if necessary. 4 American LegalNet, Inc. www.USCourtForms.com F. MEDICAL RECORD REVIEW (Use additional pages as required) In the space below, check the applicable blocks next to any test results which you reviewed and relied upon to base your medical assessments or conclusions. Be sure to show the date of each test and summarize results. Attach copy(ies) of report(s) if applicable. DATE(S) PERFORMED SUMMARY OF RESULTS Please note whether it was the actual images reviewed or if the paper report was reviewed. [ ] X-RAY # Reviewed [ ] X-RAY Reports # Reviewed [ ] EMG/NCS # Reviewed [ ] CT SCAN # Reviewed [ ] MYELOGRAM # Reviewed [ ] MRI # Reviewed [ ] OTHERS (Describe) # Reviewed 5 American LegalNet, Inc. www.USCourtForms.com G. SURGICAL PROCEDURES Please list all operative procedures performed in chronological order with the operation title noted. __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ H. IMPAIRMENT 1. As a result of this injury, did the claimant suffer a permanent impairment? YES _____ NO _____ 2. Has the claimant reached maximum medical improvement (MMI)? YES _____ NO _____ If YES, date MMI was reached ____________________ 3. Do the AMA Guides adequately assess the medical impairment rating of the claimant? Yes _____ NO ____ If YES, Please SKIP TO QUESTIONS 4 AND 5 AND PROCEED. If NO, Please express an impairment that you think is appropriate, explain the method utilized to determine it, and how you arrived at the percentage. Calculated total whole person impairment: _____% (if appropriate). __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ 6 American LegalNet, Inc. www.USCourtForms.com 4. Impairment Rating Criteria: at MMI—the residual function, the limitations of activities of daily living, the prognosis, etc. __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ 5. Using the AMA’s Physicians Guide to the Evaluation of Permanent Impairment (applicable edition) or another appropriate method, please translate the claimant’s condition to a percentage of impairment. Impairment Rating and Rationale Organ system and whole person impairment Body part or system Chapter Number Table Number Figure Number Text Cited Page Number % Impairment of the Scheduled Member % Impairment of the Whole Person If appropriate a. b. c. d. e. f. g. h. 7 American LegalNet, Inc. www.USCourtForms.com From the preceding chart, calculate the total whole person impairment: _________ %. (if appropriate) Discuss the rationale of the impairment rating and any possible inconsistencies in the examination: __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ 8 American LegalNet, Inc. www.USCourtForms.com I. PHYSICIAN CERTIFICATION AND QUALIFICATIONS It is my opinion, with a reasonable degree of medical certainty, that based upon all information available to me at the time of the MIR impairment evaluation and by utilizing the applicable AMA Guides or other appropriate method as noted above, that the claimant has the permanent impairment so described in this report. I certify that the opinion furnished is my own, that this document accurately reflects my opinion, and that I am aware that my signature attests to its truthfulness. I further certify that my statement of qualifications to serve on the MIR Registry is both current and accurate. Signature: __________________________________________ Dated: _______________ Printed full name of physician _______________________________________________ Complete and return with all required attachments via overnight delivery to: Tennessee Department of Labor and Workforce Development Workers’ Compensation Division ATTN: Jeff Francis MIR Program Coordinator 710 James Robertson Parkway, 2nd Floor Nashville, Tennessee 37243-0661 9 American LegalNet, Inc. www.USCourtForms.com