LB-0930(REV 1/18) RDA 10183 Tennessee Bureau of Workers325 Compensation 220 French Landing Drive, I-B Nashville, TN 37243-1002 800-332-2667 REQUEST TO MIR PROGRAM FOR A MEDICAL IMPAIRMENT RATING Requesting Party: Employee Employee Atty. Employer/Carrier Employer/Carrier Atty. State File # Date of Injury Date of MMI Please list all affected body part(s) or organ system(s) for which the medical impairment rating is disputed: Body Part/Organ System (i.e. finger, eye, jaw, lungs, heart, spine) Side (left or right?) Joint (hip, shoulder, wrist, elbow, knee, hip, ankle) Part of Spine ( upper, middle, lower) Employee Name SSN: DOB Phone Email Home Address City State ZIP Employee325s Attorney E-Mail Practice Name Business Address Phone Address 2 Fax City State ZIP Is an interpreter needed for the evaluation? No Yes If yes, primary language spoken Is a Bureau of Workers325 Compensation Specialist currently assigned to the case? No Yes If yes, name of the Specialist Has mediation with the Bureau been requested? No Yes If yes, scheduled date Is the Second Injury Fund involved? No Yes If yes, atty. name Employer Name American LegalNet, Inc. www.FormsWorkFlow.com LB-0930(REV 1/18) RDA 10183 Address City State ZIP Employer325s Attorney E-Mail Practice Name Business Address Phone Address 2 Fax City State ZIP Insurance Carrier Adjuster Name Email Business Address Phone Address 2 Fax City State ZIP Please list all physicians who have issued an impairment rating in this matter, indicating the body part(s) or organ system(s) evaluated, the work-related diagnosis given, and the rating issued. For back injuries, please specify whether the upper back (cervical), lower back (lumbar), or mid-back (thoracic) was rated. For extremities, please specify which joint or part (hand, thumb, wrist, elbow shoulder, hip, knee, ankle, foot, toe) and side (left or right) was rated. PHYSICIAN NAME, PRACTIC NAME, ADDRESS (Please include Street, City, State, and Zip) BODY PART/ORGAN SYSTEM EVALUATED EXACT WORK-RELATED DIAGNOSIS IMPAIRMENT RATING (1) (2) (3) (4) (5) (6) American LegalNet, Inc. www.FormsWorkFlow.com LB-0930(REV 1/18) RDA 10183 Please provide the names of all treating physicians in this case. PHYSICIAN NAME, PRACTIC NAME, ADDRESS (Please include Street, City, State, and Zip) (1) (8) (2) (9) (3) (10) (4) (11) (5) (12) (6) (13) (7) (14) Certificate of Mailing The requesting party shall send a copy of this application to the other party and to the Program. 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 Employee325s Attorney Employer325s Attorney Insurance Carrier I hereby request the Tennessee Bureau of Workers325 Compensation to provide a list of MIR Physicians to help resolve the dispute related to the above-detailed injury. If appropriate, I am including, with this Request Form, a copy of the Form C-42 Choice of Physician Panel and a copy of the permanent restrictions if this request is due to 0% Impairment Rating that included permanent restrictions. Printed name Signature Date American LegalNet, Inc. www.FormsWorkFlow.com