STATE OF TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT Workers’ Compensation Division Medical Impairment Rating Program 220 French Landing Drive Nashville, TN 37243-1002 (615) 253-1613 (615) 253-5263 fax Application for Appointment to the Medical Impairment Rating (MIR) Registry What factors does the Medical Director consider in approving, disapproving, suspending, or removing doctors from the approved Medical Impairment Rating Registry? The Medical Director may consider several factors. Examples include, but are not limited to: 1. Achieving and maintaining Board certification; 2. Having and maintaining a current active and unrestricted license to practice medicine in Tennessee; 3. Having and maintaining adequate malpractice insurance; 4. Proof of completion of an accepted course regarding the application of the relevant edition of the AMA Guides; 5. Geographical need of the Department; 6. Misrepresentation on the application for appointment to the Registry; 7. Acceptance of the Department’s established MIR fee; 8. Ability to effectively convey and substantiate medical opinions and conclusions concerning impairment ratings; 9. Quality and timeliness of reports; 10. Complaints from workers about the conduct of the physician; 11. Disciplinary proceedings or actions; 12. Failure to report prior involvement or conflict of interest in case assignments; 13. Any other reason for the good of the Registry, as determined by the Commissioner. Type of Application: _____ New Member _____ Renewal _____ Reinstatement Please complete the following information: Your name_____________________________________________________________________ MD_____ DO_____ Check one License # _________________ Group/Practice d/b/a ____________________________________________________ Mailing Address 1 ________________________________________________________________________________ Please provide actual office street address(es) on a separate sheet Mailing Address 2 ________________________________________________________________________________ City_______________________________________________________ State_______ Zip______________________ E-Mail_______________________ Phone #______________________ ext _____ Fax #________________________ Have you had charges/actions on your license to practice in any state or country? Have you been charged with a felony or other criminal activity or gross misdemeanor? Do you have hospital privileges? _____ NO _____ YES _____ NO _____YES _____ NO _____YES Please attach a copy of charges or actions. Please give details on a separate sheet. Please name all hospital(s) and city(ies). _______________________________________________ __________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________ LB-0928 (REV. 12/07) Application for Appointment to the Medical Impairment Rating (MIR) Registry RDA 10183 Pg. 1 of 4 American LegalNet, Inc. www.FormsWorkflow.com Please provide the office address(es) for each location that you will use to perform evaluations. Group/Practice d/b/a ______________________________________________________________________________ Office Street Address 1 ____________________________________________________________________________ Office Street Address 2 ____________________________________________________________________________ City_______________________________________________________ State_______ Zip______________________ E-Mail_______________________ Phone #______________________ ext _____ Fax #________________________ Group/Practice d/b/a ______________________________________________________________________________ Office Street Address 1 ____________________________________________________________________________ Office Street Address 2 ____________________________________________________________________________ City_______________________________________________________ State_______ Zip______________________ E-Mail_______________________ Phone #______________________ ext _____ Fax #________________________ Group/Practice d/b/a ______________________________________________________________________________ Office Street Address 1 ____________________________________________________________________________ Office Street Address 2 ____________________________________________________________________________ City_______________________________________________________ State_______ Zip______________________ E-Mail_______________________ Phone #______________________ ext _____ Fax #________________________ Group/Practice d/b/a ______________________________________________________________________________ Office Street Address 1 ____________________________________________________________________________ Office Street Address 2 ____________________________________________________________________________ City_______________________________________________________ State_______ Zip______________________ E-Mail_______________________ Phone #______________________ ext _____ Fax #________________________ Group/Practice d/b/a ______________________________________________________________________________ Office Street Address 1 ____________________________________________________________________________ Office Street Address 2 ____________________________________________________________________________ City_______________________________________________________ State_______ Zip______________________ E-Mail_______________________ Phone #______________________ ext _____ Fax #________________________ LB-0928 (REV. 12/07) Application for Appointment to the Medical Impairment Rating (MIR) Registry RDA 10183 Pg. 2 of 4 American LegalNet, Inc. www.FormsWorkflow.com Have your hospital privileges in any state or country ever been modified or withdrawn? Do you carry medical malpractice insurance? _____ NO _____ YES _____ NO _____YES If yes, please give details on separate sheet. If yes, Policy # ________________________________________________________ Carrier Name _______________________________________________________________ Carrier Phone # ___________________________________________ List your specialty areas: ______________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________ List all chapters of the AMA Guides that you are competent to use: ____________________________________________________________________________ Zip Codes where you have office space sufficient to perform MIRs._____________________________________________________________________________ Doctors licensed to perform medicine and surgery or osteopathic medicine and surgery please complete the following: I am certified by a board recognized by: _____ American Board of Medical Specialties Name of Board(s) _______________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ _____ American Osteopathic Association Name of Board(s) _______________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ _____ Other: ________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ Note: Please attach a copy of your curriculum vitae, medical license and board certification(s). Are you certified by any medical society or organization in disability and/or impairment evaluation and ratings? _____ NO _____ YES, _________________________________________________________ If yes, name(s) of society(ies) or organization(s) and date certified. Please submit proof with application. Approximate number of impairment ratings you have performed in the last 24 months. _______________ Total CE credits in the fields of impairment rating, performance of medical impairment ratings and/or occupational injury and disease obtained within the last two (2) years. _______ (Provide proof of attendance) Date Name of course Sponsor # of credit hours ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ LB-0928 (REV. 12/07) Application for Appointment to the Medical Impairment Rating (MIR) Registry RDA 10183 Pg. 3 of 4 American LegalNet, Inc. www.FormsWorkflow.com I request appointment to the Medical Impairment Rating (MIR) Registry. I will provide independent, objective, and timely impairment ratings in all cases that come before me. I understand that it is the expectation of the Department that all workers will be treated with dignity and respect. I understand my performance will be measured by the quality and timeliness of my evaluations and reports and not by whether my recommendations are perceived as favorable or unfavorable to the parties involved. I also understand that I am not guaranteed referrals. I understand that only fully qualified physicians, as determined solely by the Commissioner of the Tennessee Department of Labor and Workforce Development or his designee, will be approved. I certify that I have sufficient knowledge of the applicable edition of the AMA Guides to the Evaluation of Permanent Impairment to adequately conduct impairment evaluations and to assign appropriate impairment ratings. I will not base my findings on the absence or presence of an attorney in the case or on the potential size of an award. If I am offered financial awards to influence my decision, I will immediately report the situation to the Commissioner’s office of the Tennessee Department of Labor and Workforce Development. I realize that evaluations performed for the Department are paid according to a published fee schedule. I have provided complete and accurate information regarding the status of my license, my specialties, and ability to practice. I will immediately notify the MIR Program Coordinator and provide a copy of the charges or final order should any of the following situations occur: 1. 2. 3. Any temporary or permanent probation, suspension, revocation, or limitation is placed on my license to practice by any court, board, or administrative agency; I am charged with any crime, gross misdemeanor, felony, or violation of statutes or rules by any administrative agency, court, or board; I am convicted of any crime, gross misdemeanor, felony or violation of statutes or rules by any administrative agency, court, or board. I understand that: • • • • It is my responsibility to inform the MIR Program Coordinator in writing if there is any change in the status of my practice or license and of any current or completed action of any nature. If I do not meet criteria I may not be approved as an MIR physician. The privilege of continuing as an MIR physician is not guaranteed. If approved, I may be removed from the Registry at any time on the basis of factors including, but not limited to: • • • • • A misrepresentation on the “Application for Appointment to the Medical Impairment Rating (MIR) Registry”; Failure to report prior involvement or conflict of interest in a case assignment; Refusal and/or substantial failure to comply with the provisions of the Rules of procedure including repeated failure to determine impairment ratings correctly using the AMA Guides, as determined by the Medical Director; Inability to maintain the requirements of the Rules as determined by the Program Coordinator; or Any other reason for the good of the MIR Registry, totally in the discretion of the Commissioner. ___________________________________ ___________________ Signature Date LB-0928 (REV. 12/07) Application for Appointment to the Medical Impairment Rating (MIR) Registry RDA 10183 Pg. 4 of 4 American LegalNet, Inc. www.FormsWorkflow.com