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 Medical Impairment Rating (MIR) Medical Waiver and Consent It is a crime to knowingly provide false, incomplete or misleading information to any party to a workers’ compensation transaction for the purpose of committing fraud. Penalties include imprisonment, fines and denial of insurance benefits. I, ____________________________________________________________________ , having filed a claim for workers’ compensation benefits, do hereby waive any physician-patient, psychiatrist-patient, or chiropractor-patient privilege I may have and hereby authorize any physician, psychiatrist, chiropractor, podiatrist, hospital, or health care provider to furnish to the MIR physician designated by the Tennessee Department of Labor and Workforce Development, Workers’ Compensation Division any information or written material reasonably related to my work-related injury or my past relevant medical history. 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, and impairment ratings. This authorization shall remain valid for 180 days following its execution. A fax or photocopy of the authorization may be accepted in lieu of the original. Signed at ______________________________, Tennessee, this ___________________ day of __________________________ , 20 ______ . ________________________________________________ Signature ________________________________________________ SSN ________________________________________________ Witness Pursuant to Tennessee Code Annotated Session 50-6-204, any physician, psychiatrist, chiropractor, podiatrist, hospital or health care provider shall, within a reasonable time, not to exceed thirty (30) days, provide the requesting party with any information or written material reasonably related to the injury for which the employee claims compensation. LB-0929 (REV. 12/07) RDA 10183 American LegalNet, Inc. www.FormsWorkflow.com