Tennessee > Workers Compensation
Medical Impairment Rating (MIR) Impairment Rating Report - Tennessee
| Medical Impairment Rating (MIR) Impairment Rating Report Form. This is a Tennessee form and can be used in Workers Compensation . |
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STATE OF TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT Workers' Compensation Division Medical Impairment Rating Program Andrew Johnson Tower 710 James Robertson Parkway, 2nd Floor Nashville, TN 37243-0655 (615) 253-1613 (615) 253-5263 fax Medical Impairment Rating (MIR) Impairment Rating Report A. PATIENT INFORMATION (please type or neatly print all responses) Claimant Name ____________________________________________________________________________ Address ___________________________________________________________________________________ City, State, Zip ______________________________________________ Phone # _______________________ State File # __________________________________ MIR case # ____________________________________ Social security # _____________________________ Date of Birth ___________________________________ Date of Injury ____________________________ Date of MIR Evaluation ____________________________ B. MIR PHYSICIAN INFORMATION MIR Physician Name _______________________________________________________________________ Address __________________________________________________________________________________ City, State, Zip _____________________________________________ Phone #________________________ Location of evaluation if different than above) __________________________________________________ __________________________________________________________________________________________ LB-0931 RDA 10183 1 American LegalNet, Inc. www.USCourtForms.com C. PATIENT HISTORY INTRODUCTION AND OVERVIEW (brief description of the injury/illness, prior treatment received, and periods claimant was unable to work) __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ 2 American LegalNet, Inc. www.USCourtForms.com D. PHYSICAL EXAMINATION __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ ______________________________________
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