Free MIR Impairment Rating Report - 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 (615) 253-1613 (615) 253-5263 fax

Medical Impairment Rating (MIR)Report AMA Guides, 5th Edition

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 #______________________________________ Fax _________________________________________ Location of evaluation if different than above) __________________________________________________ __________________________________________________________________________________________

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C.

PATIENT HISTORY
INTRODUCTION AND OVERVIEW (brief description of the injury/illness, prior treatment received, and periods claimant was unable to work) __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________

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D.

PHYSICAL EXAMINATION
__________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ _________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________

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E.
Name & Address of All treatment Providers

CLAIMANT'S CHRONOLOGICAL MEDICAL HISTORY
Date Treatment Received Nature of the injury or illness? Part of the body affected?

Make additional copies if necessary.
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F.

MEDICAL RECORD REVIEW (Use additional pages as required)

In the space below, check the applicable blocks next to any test results which you reviewed and relied upon to base your medical assessments or conclusions. Be sure to show the date of each test and summarize results. Attach copy(ies) of report(s) if applicable.

DATE(S) PERFORMED
Please note whether it was the actual images reviewed or if the paper report was reviewed.

SUMMARY OF RESULTS

[

]

X-RAY

# Reviewed

[

]

X-RAY Reports

# Reviewed

[

]

EMG/NCS

# Reviewed

[

]

CT SCAN

# Reviewed

[

]

MYELOGRAM

# Reviewed

[

]

MRI

# Reviewed

[

]

OTHERS (Describe)

# Reviewed

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G.

SURGICAL PROCEDURES
Please list all operative procedures performed in chronological order with the operation title noted. __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________

H.
1. 2. 3.

IMPAIRMENT
Does the claimant have a permanent impairment? YES _____ NO _____ Has the claimant reached maximum medical improvement (MMI)? YES _____ NO _____ If YES, date MMI was reached ____________________ If NO, SKIP TO SECTION I on PAGE 9. Do the AMA Guides adequately assess the medical impairment rating of the claimant? Yes _____ NO ____ If YES, Please SKIP TO QUESTIONS 4 AND 5 AND PROCEED. If NO, Please express an impairment that you think is appropriate, explain the method utilized to determine it, and how you arrived at the percentage. Calculated total whole person impairment: _____% (if appropriate). __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________

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4.

Impairment Rating Criteria: at MMI--the residual function, the limitations of activities of daily living, the prognosis, etc. __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________

5.

Using the AMA's Physicians Guide to the Evaluation of Permanent Impairment (applicable edition) or another appropriate method, please translate the claimant's condition to a percentage of impairment.

Impairment Rating and Rationale Organ system and whole person impairment
Body part or system Chapter Number Table Number Figure Number Text Cited Page Number
% Impairment of the Scheduled Member % Impairment of the Whole Person If appropriate

a.

b.

c.

d.

e.

f.

g.

h.

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From the preceding chart, calculate the total whole person impairment: _________ %. (if appropriate) Discuss the rationale of the impairment rating and any possible inconsistencies in the examination: __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________
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I.

PHYSICIAN CERTIFICATION AND QUALIFICATIONS "It is my opinion, both within and to a reasonable degree of medical certainty that, based upon all information available to me at the time of the MIR impairment evaluation and by utilizing the relevant AMA Guides or other appropriate method as noted above, that the claimant has the permanent impairment so described in this report. I certify that the opinion furnished is my own, that this document accurately reflects my opinion, and that I am aware that my signature attests to its truthfulness. I further certify that my statement of qualifications to serve on the MIR Registry is both current and completely accurate." Signature: __________________________________________ Dated: _______________ Printed full name of physician _______________________________________________

CLEAR FORM
Complete and return with all required attachments via overnight delivery to: Tennessee Department of Labor and Workforce Development Workers' Compensation Division ATTN: J. Edward Blaisdell MIR Program Coordinator 220 French Landing Drive Nashville, TN 37243-1002

LB-0931 (REV. 4/09)

Medical Impairment Rating (MIR) Report, AMA 5th Edition

RDA 10183 Pg. 9 of 9