STATE OF TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT Workers’ Compensation Division Medical Impairment Rating Program 220 French Landing Drive Nashville, TN 37243-1002 Phone (615) 253-1613 Fax (615) 253-5263 Application for a Medical Impairment Rating (MIR) Requesting Party (check one) _____ Employee _____ Employer _____ Insurance Carrier Name of person requesting MIR _________________________________________________________ Contact Information: Phone # _______________________ E-mail ____________________________ Relationship to the Requesting party _____________________________________________________ (Attorney, Union Representative, Family member, etc.) State File # ________________________ Date of Injury ___________ Date of MMI____________ Employee Name SSN # ________________________ DOB _________________________ Home Address_________________________________________ E-Mail ________________________ City _____________________________________ State ____ Zip _______ Phone # _______________ Employee’s Attorney ____________________________________ E-Mail _______________________ Practice Name _______________________________________________________________________ Business Address _______________________________________ Phone # ______________________ Address 2 _____________________________________________ Fax # _________________________ City ___________________________________________ State _______ Zip _____________________ Employer Name _______________________________________ FEIN # ________________________ Contact Name ________________________________________ Title ___________________________ Business Address____________________________________________ Phone # __________________ Address 2 __________________________________________________ Fax # ____________________ City __________________________________________ State ________ Zip _____________________ Employer’s Attorney ____________________________________ E-Mail________________________ LB-0930 (REV. 3/10) APPLICATION FOR A MEDICAL IMPAIRMENT RATING (MIR) RDA 10183 Pg. 1 of 5 American LegalNet, Inc. www.FormsWorkFlow.com Practice Name _______________________________________________________________________ Business Address ______________________________________________ Phone # ________________ Address 2 ____________________________________________________ Fax # __________________ City ___________________________________________ State _______ Zip _____________________ PLEASE SEND A COPY OF THE C-42 (CHOICE OF PHYSICAN) FORM. Insurance Carrier _________________________________________ E-Mail _____________________ Adjuster Name _______________________________________ Title ___________________________ Business Address ________________________________________ Phone # ______________________ Address 2 ______________________________________________ Fax # ________________________ City ___________________________________________ State _______ Zip _____________________ Please designate the specific body part(s) and all conditions to be evaluated. _____ Upper Extremities _____ Lower Extremities _____ Skin (Arms, Hands and/or Fingers including shoulders, elbows and wrists) (Legs, Feet and/or Toes including hips, knees and ankles) (Including Scars, Skin grafts, Dermatitis, Rubber latex allergies, and Skin cancer) _____Spine or Neck ____ Spine or Neck AND Spinal Cord _____ Mental and Behavioral Disorders (Including psychiatric impairment) _____ Central and Peripheral Nervous System _____ Heart or Cardiovascular System _____ Lungs or Respiratory System (Including injuries to the Brain, Gait and movement disorders, Chronic pain, and Neuromuscular injuries) (Including Heart diseases Arrhythmias, and Cardiomyopathies) (Including Asthma, Sleep apnea, Pneumoconiosis, and Lung cancer) _____ Ear, Nose, and Throat _____ Bone Marrow, Lymph nodes, Spleen, White blood cell diseases, and Blood-circulating _____ Digestive System and related structures (Including Facial disfigurement, Hearing loss, Voice and/or Speech impairment, and Chewing and/or swallowing impairment) cells _____ Eyes and the Visual System _____ Endocrine System _____ Urinary and Reproductive Systems (Including (Including the Thyroid, Gonads the Bladder and/or Urethra) (Including the Colon, Liver and/or Hernias) and/or Pancreas) _____ Female Breast LB-0930 (REV. 3/10) APPLICATION FOR A MEDICAL IMPAIRMENT RATING (MIR) RDA 10183 Pg. 2 of 5 American LegalNet, Inc. www.FormsWorkFlow.com Is a Workers’ Comp Specialist currently assigned to the case? _______ NO _______ YES If so, name of Specialist ________________________ Office Location _________________________ Has a Benefit Review Conference been requested? ____ NO ____ YES __________________________ If so, scheduled date Is the Second Injury Fund involved? _______ NO _______ YES ___________________________ If so, attorney’s name Is an interpreter needed for the evaluation? _____NO _____YES _____________________________ If so, primary language spoken Medical Treatment Information Names of all physicians who have issued an impairment rating in this matter and the rating issued. Medical Impairment Rating Physician Name ___________________________________________________________ ________________________ ___________________________________________________________ ________________________ ___________________________________________________________ ________________________ ___________________________________________________________ ________________________ ___________________________________________________________ ________________________ Names of physicians made available to the injured worker. Use additional form if necessary. Physician Name __________________________________________ Phone # _______________________ Practice Name _______________________________________________________________________ Office Address ________________________________________ _________________ ____ _________ Street City State Zip Physician Name ____________________________________________Phone # _____________________ Practice Name ________________________________________________________________________ Office Address Street City State Zip Physician Name __________________________________________ Phone # _______________________ Practice Name ________________________________________________________________________ Office Address Street LB-0930 (REV. 3/10) City APPLICATION FOR A MEDICAL IMPAIRMENT RATING (MIR) State Zip RDA 10183 Pg. 3 of 5 American LegalNet, Inc. www.FormsWorkFlow.com Names of all employer-paid treating physicians in this case Physician Name __________________________________________ Phone # _______________________ Practice Name _______________________________________________________________________ Office Address Street City State Zip Physician Name __________________________________________ Phone # _______________________ Practice Name _______________________________________________________________________ Office Address Street City State Zip Physician Name __________________________________________ Phone # _______________________ Practice Name _______________________________________________________________________ Office Address Street City State Zip Names of all employee-paid treating physicians in this case Physician Name __________________________________________ Phone # _______________________ Practice Name _______________________________________________________________________ Office Address Street City State Zip Physician Name __________________________________________ Phone # _______________________ Practice Name _______________________________________________________________________ Office Address Street City State Zip Certificate of Mailing The requesting party shall send a copy of this application to the other party and to the Program Coordinator. Copies of this document were placed in the U.S. Mail or delivered to the following parties this _________ day of _________________, 20_______. Circle all persons copied: Employee Employee’s Attorney Employer’s Attorney Insurance Carrier By: Signature LB-0930 (REV. 3/10) APPLICATION FOR A MEDICAL IMPAIRMENT RATING (MIR) Date RDA 10183 Pg. 4 of 5 American LegalNet, Inc. www.FormsWorkFlow.com Informational Summary The following is a brief outline of the Workers’ Compensation Medical Impairment Rating process. 1. To obtain the legal presumption of accuracy for the resulting impairment rating report afforded in Section 50-6-204(d)(5) of the Act, the parties must select the physician to conduct the evaluation pursuant to the procedures stated in the rules governing the MIR program. 2. Either party may request an impairment evaluation. The requesting party is responsible for completing this form. Within five (5) calendar days of receiving this application, the Program Coordinator will produce the listing requested and will provide those names to the parties. 3. If the parties are unable to mutually agree on a selection from the initial listing provided, either party may request a three-physician assignment from the Registry. 4. After a three-physician assignment has been supplied, the employer will have three (3) business days to strike one name from the listing and to notify the employee and the Program Coordinator. The employee then has three (3) business days to strike another name and to notify the Program Coordinator and the employer of the remaining name. If one party fails to timely strike a name, the other party should promptly notify the Program Coordinator of the name that it wishes to strike and to request assistance. Time extensions will be granted only for good cause shown. 5. The Program Coordinator will notify the selected physician and will schedule the appointment. 6. If necessary, the claimant shall promptly sign a release form permitting the release of all pertinent medical records. Both parties must submit all pertinent medical records to the chosen physician and the other party at least ten (10) calendar days prior to the evaluation. Supplemental medical records must be submitted at least five (5) calendar days prior to the evaluation or as otherwise arranged by the Program Coordinator. In cases involving incomplete medical record submission, the other party should notify the Program Coordinator for assistance. 7. The employer is responsible for paying for the evaluation. 8. The physician shall submit the MIR evaluation report to the Program Coordinator, only. 9. If the parties want to cancel the evaluation, they should contact the MIR Program Coordinator. LB-0930 (REV. 3/10) APPLICATION FOR A MEDICAL IMPAIRMENT RATING (MIR) RDA 10183 Pg. 5 of 5 American LegalNet, Inc. www.FormsWorkFlow.com