Form LB-0929 "Mir Medical Waiver and Consent Form" - Tennessee

What Is Form LB-0929?

This is a legal form that was released by the Tennessee Department of Labor and Workforce Development - a government authority operating within Tennessee. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on September 1, 2016;
  • The latest edition provided by the Tennessee Department of Labor and Workforce Development;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form LB-0929 by clicking the link below or browse more documents and templates provided by the Tennessee Department of Labor and Workforce Development.

ADVERTISEMENT
ADVERTISEMENT

Download Form LB-0929 "Mir Medical Waiver and Consent Form" - Tennessee

Download PDF

Fill PDF online

Rate (4.6 / 5) 66 votes
Page background image
Tennessee Bureau of Workers’ Compensation
220 French Landing Drive, I-B
Nashville, TN 37243-1002
800-332-2667
http://www.tn.gov/workforce/article/medical-impairment-rating-mir-registry
MEDICAL IMPAIRMENT RATING (MIR) MEDICAL WAIVER AND CONSENT
I,
, having filed a claim for workers’ compensation benefits, do
(Printed name)
hereby waive any physician-patient, psychiatrist-patient, or chiropractor-patient privilege I may have
and hereby authorize any physician, psychiatrist, chiropractor, podiatrist, hospital, health care
provider, or the Tennessee Bureau of Workers’ Compensation to furnish to the MIR physician
designated by the Tennessee Bureau of Workers’ Compensation and/or to provide to my
employer, or my employer’s representative, any information or written material reasonably
related to my work-related injury or my past relevant medical history. I further authorize the release of
the same information to me or my attorney.
This authorization includes, but is not restricted to, a right to review and obtain copies of all
records, medical imaging films and reports, electrodiagnostic testing, hospital records, surgery center
records, medical charts, prescriptions, diagnoses, opinions and course of treatment, and impairment
ratings.
This authorization shall remain valid until the release of the MIR Report by the MIR Registry Program
Coordinator or the withdrawal of the MIR Request. . A fax or photocopy of the authorization may be
accepted in lieu of the original.
Signed at
, Tennessee, this
day of
, 20
.
Signature
SSN
Witness
Date
Pursuant to the Tennessee Code Annotated, any physician, psychiatrist, chiropractor, podiatrist, hospital
or health care provider or governmental agency shall, within a reasonable time, not to exceed thirty (30)
days, provide the MIR Program Coordinator with any information or medical records authorized above.
LB-0929 (REV 9/16)
RDA 10183
Tennessee Bureau of Workers’ Compensation
220 French Landing Drive, I-B
Nashville, TN 37243-1002
800-332-2667
http://www.tn.gov/workforce/article/medical-impairment-rating-mir-registry
MEDICAL IMPAIRMENT RATING (MIR) MEDICAL WAIVER AND CONSENT
I,
, having filed a claim for workers’ compensation benefits, do
(Printed name)
hereby waive any physician-patient, psychiatrist-patient, or chiropractor-patient privilege I may have
and hereby authorize any physician, psychiatrist, chiropractor, podiatrist, hospital, health care
provider, or the Tennessee Bureau of Workers’ Compensation to furnish to the MIR physician
designated by the Tennessee Bureau of Workers’ Compensation and/or to provide to my
employer, or my employer’s representative, any information or written material reasonably
related to my work-related injury or my past relevant medical history. I further authorize the release of
the same information to me or my attorney.
This authorization includes, but is not restricted to, a right to review and obtain copies of all
records, medical imaging films and reports, electrodiagnostic testing, hospital records, surgery center
records, medical charts, prescriptions, diagnoses, opinions and course of treatment, and impairment
ratings.
This authorization shall remain valid until the release of the MIR Report by the MIR Registry Program
Coordinator or the withdrawal of the MIR Request. . A fax or photocopy of the authorization may be
accepted in lieu of the original.
Signed at
, Tennessee, this
day of
, 20
.
Signature
SSN
Witness
Date
Pursuant to the Tennessee Code Annotated, any physician, psychiatrist, chiropractor, podiatrist, hospital
or health care provider or governmental agency shall, within a reasonable time, not to exceed thirty (30)
days, provide the MIR Program Coordinator with any information or medical records authorized above.
LB-0929 (REV 9/16)
RDA 10183