Tennessee > Workers Compensation
Application For A Medical Impairment Rating (MIR) - Tennessee
| Application For A Medical Impairment Rating (MIR) Form. This is a Tennessee form and can be used in Workers Compensation . |
|
||||||
 Get this form for FREE as a print-only pdf |
|||||||
|
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 (Arms, Hands and/or Fingers including shoulders, elbows and wrists) _____ Lower Extremities (Legs, Feet and/or Toes including hips, knees and ankles) _____ Skin (Including Scars, Skin grafts, Dermatitis, Rubber latex allergies, and Skin cancer) _____Spine or Neck ____ Spine or Neck AND Spinal Cord _____ Heart or Cardiovascular System (Including Heart diseases Arrhythmias, and Cardiomyopathies) _____ Mental and Behavioral Disorders (Including psychiatric impairment) _____ Central and Peripheral Nervous System (Including injuries to the Brain, Gait and movement disorders, Chronic pain, and Neuromuscular injuries) _____ Lungs or Respiratory System (Including Asthma, Sleep apnea, Pneumoconiosis, and Lung cancer) _____ Ear, Nose, and Throat and related structures (Including Facial disfigurement, Hearing loss, Voice and/or Speech impairment, and Chewing and/or swallowing impairment) _____ Bone Marrow, Lymph nodes, Spleen, White blood cell diseases, and Blood-circulating cells _____ Digestive System (Including the Colon, Liver and/or Hernias) _____ Eyes and the Visual System _____ Female Breast _____ Endocrine System _____ Urinary and Reproductive Systems (Including (Including the Thyroid, Gonads the Bladder and/or Urethra) and/or Pancreas) 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 Is the Second Injury Fund involved? __________________________ If so, scheduled date _______ NO _______ YES ___________________________ If so, attorney's name If so, primary language spoken Is an interpreter needed for the evaluation? _____NO _____YES _____________________________ Medical Treatment Information Names of all physicians who have issued an impairment rating in this matter and the rating issued. Physician Name Medical Impairment Rating ___________________________________________________________ ________________________ ___________________________________________________________ ________________________ ___________________________________________________________ ________________________ ___________________________________________________________ ________________________ ___________________________________________________________ ________________________ 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 City State Zip LB-0930 (REV. 3/10) APPLICATION FOR A MEDICAL IMPAIRMENT RATING (MIR) RDA 10183 Pg. 3 of 5 American LegalNe
|
|||||||
