Free Application for an Independent Medical Examiner (IME) - Tennessee

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________________________
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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)

__ Neck or Back __ Central and Peripheral Nervous System
(Including injuries to the Brain, Gait and movement disorders, Chronic pain, and Neuromuscular injuries) __ Ear, Nose, and Throat and related structures (Including Facial disfigurement, Hearing loss, Voice and/or Speech impairment, and Chewing and/or swallowing impairment)

__ The spine and spinal cord __ Heart or Cardiovascular System
(Including Heart diseases Arrhythmias, and Cardiomyopathies)

__ Mental and Behavioral Disorders (Including psychiatric
impairment)

__ Lungs or Respiratory System
(Including Asthma, Sleep apnea, Pneumoconiosis, and Lung cancer)

__ 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

__ Urinary and Reproductive Systems (Including the Bladder
and/or Urethra)

__ Endocrine System (Including the Thyroid, Gonads and/or Pancreas)

Is a Workers' Comp Specialist currently assigned to the case?
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__ NO

__ YES
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If so, name of Specialist ________________________ Office Location _________________________
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Has a Benefit Review Conference been requested? __ NO __ YES

__________________________
If so, scheduled date

Is an interpreter needed for the evaluation? __ NO __ YES _____________________________
If so, primary language spoken

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

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Names of all employer-paid treating physicians in this case 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

Names of all employee-paid treating physicians in this case Physician Name __________________________________________ Phone # _______________________ Practice Name _______________________________________________________________________ Office Address
Street City State Zip

Physician Name __________________________________________ Phone # _______________________ Practice Name _______________________________________________________________________ Office Address
Street City State Zip

Certificate of Mailing The requesting party shall send a copy of this application to the other party and to the Program Coordinator. 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 By: Employee's Attorney
Signature

Employer's Attorney

Insurance Carrier
Date

CLEAR FORM
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Informational Summary The following is a brief outline of the Workers' Compensation Medical Impairment Rating process. 1. To obtain the legal presumption of accuracy for the resulting impairment rating report afforded in Section 50-6-204(d)(5) of the Act, the parties must select the physician to conduct the evaluation pursuant to the procedures stated in the rules governing the MIR program. 2. Either party may request an impairment evaluation. The requesting party is responsible for completing this form. Within five (5) calendar days of receiving this application, the Program Coordinator will produce the listing requested and will provide those names to the parties. 3. If the parties are unable to mutually agree on a selection from the initial listing provided, either party may request a three-physician assignment from the Registry. 4. After a three-physician assignment has been supplied, the employer will have three (3) business days to strike one name from the listing and to notify the employee and the Program Coordinator. The employee then has three (3) business days to strike another name and to notify the Program Coordinator and the employer of the remaining name. If one party fails to timely strike a name, the other party should promptly notify the Program Coordinator of the name that it wishes to strike and to request assistance. Time extensions will be granted only for good cause shown. 5. The Program Coordinator will notify the selected physician and will schedule the appointment. 6. If necessary, the claimant shall promptly sign a release form permitting the release of all pertinent medical records. Both parties must submit all pertinent medical records to the chosen physician and the other party at least ten (10) calendar days prior to the evaluation. Supplemental medical records must be submitted at least five (5) calendar days prior to the evaluation or as otherwise arranged by the Program Coordinator. In cases involving incomplete medical record submission, the other party should notify the Program Coordinator for assistance. 7. The employer is responsible for paying for the evaluation. 8. The physician shall submit the MIR evaluation report to the Program Coordinator, only. 9. If the parties want to cancel the evaluation, they should contact the MIR Program Coordinator.

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