Form LB-0928 "Physician Application for Appointment to the Medical Impairment Rating (Mir) Registry" - Tennessee

What Is Form LB-0928?

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 November 1, 2015;
  • 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-0928 by clicking the link below or browse more documents and templates provided by the Tennessee Department of Labor and Workforce Development.

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Download Form LB-0928 "Physician Application for Appointment to the Medical Impairment Rating (Mir) Registry" - Tennessee

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Tennessee Bureau of Workers’ Compensation
220 French Landing Drive, I-B
Nashville, TN 37243-1002
800-332-2667
PHYSICIAN APPLICATION FOR APPOINTMENT TO THE
MEDICAL IMPAIRMENT RATING (MIR) REGISTRY
Name______________________________________________________________________ MD_____ DO_____
Check one
License # ____________________ Group/Practice d/b/a ____________________________________________________
Mailing Address ______________________________________________ Phone #______________________ ext _____
Please provide actual office street address(es) on a separate sheet
City_______________________________________________________ State_______ Zip________________________
Have you had charges/actions on your license to practice in any state or country?
_____ NO _____YES
Please attach a copy of charges or actions.
Have you been charged with a felony or other criminal activity or gross misdemeanor?
_____ NO _____YES
Please give details on a separate sheet.
Do you have hospital privileges? _____ NO _____ YES
Please name all hospital(s) and city(ies). ___________________________________________________
_______________________________________________________________________________________________________________________________________
Have your hospital privileges in any state or country ever been modified or withdrawn? _____ NO _____YES
If yes, please give details on separate sheet.
List your specialty areas: __________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
List all chapters of the AMA Guides that you are competent to use: ________________________________________________________________________________
Please provide the office address(es) for each location that you will use to perform evaluations. Use additional
sheets if necessary.
Group/Practice d/b/a _________________________________________________________________________________
Office Street Address 1 ______________________________________________________________________________
City_______________________________________________________ State_______ Zip________________________
Office Contact ___________________________ E-Mail_______________________ Fax #________________________
Group/Practice d/b/a _________________________________________________________________________________
Office Street Address 1 ______________________________________________________________________________
City_______________________________________________________ State_______ Zip________________________
Office Contact ___________________________ E-Mail_______________________ Fax #________________________
LB-0928 (REV 11/15)
RDA 10183
1
Tennessee Bureau of Workers’ Compensation
220 French Landing Drive, I-B
Nashville, TN 37243-1002
800-332-2667
PHYSICIAN APPLICATION FOR APPOINTMENT TO THE
MEDICAL IMPAIRMENT RATING (MIR) REGISTRY
Name______________________________________________________________________ MD_____ DO_____
Check one
License # ____________________ Group/Practice d/b/a ____________________________________________________
Mailing Address ______________________________________________ Phone #______________________ ext _____
Please provide actual office street address(es) on a separate sheet
City_______________________________________________________ State_______ Zip________________________
Have you had charges/actions on your license to practice in any state or country?
_____ NO _____YES
Please attach a copy of charges or actions.
Have you been charged with a felony or other criminal activity or gross misdemeanor?
_____ NO _____YES
Please give details on a separate sheet.
Do you have hospital privileges? _____ NO _____ YES
Please name all hospital(s) and city(ies). ___________________________________________________
_______________________________________________________________________________________________________________________________________
Have your hospital privileges in any state or country ever been modified or withdrawn? _____ NO _____YES
If yes, please give details on separate sheet.
List your specialty areas: __________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
List all chapters of the AMA Guides that you are competent to use: ________________________________________________________________________________
Please provide the office address(es) for each location that you will use to perform evaluations. Use additional
sheets if necessary.
Group/Practice d/b/a _________________________________________________________________________________
Office Street Address 1 ______________________________________________________________________________
City_______________________________________________________ State_______ Zip________________________
Office Contact ___________________________ E-Mail_______________________ Fax #________________________
Group/Practice d/b/a _________________________________________________________________________________
Office Street Address 1 ______________________________________________________________________________
City_______________________________________________________ State_______ Zip________________________
Office Contact ___________________________ E-Mail_______________________ Fax #________________________
LB-0928 (REV 11/15)
RDA 10183
1
Are you certified by any medical society or organization in disability and/or impairment evaluation and ratings?
_____ NO _____ YES, _________________________________________________________
If yes, name(s) of society(ies) or organization(s) and date certified. Please submit proof with application.
Approximate number of impairment ratings you have performed in the last 24 months. _______________
I request appointment to the Medical Impairment Rating (MIR) Registry. I will provide independent, objective, and timely
impairment ratings in all cases that come before me. I understand that it is the expectation of the Tennessee Bureau of Workers’
Compensation that all workers will be treated with dignity and respect.
I understand my performance will be measured by the quality and timeliness of my evaluations and reports and not by whether my
recommendations are perceived as favorable or unfavorable to the parties involved. I also understand that I am not guaranteed
referrals.
I understand that only fully qualified physicians, as determined solely by the Administrator of the Bureau or his/her designee, will be
approved. I certify that I have sufficient knowledge of the applicable edition of the AMA Guides to the Evaluation of Permanent
Impairment to adequately conduct impairment evaluations and to assign appropriate impairment ratings.
I will not base my findings on the absence or presence of an attorney in the case or on the potential size of an award. If I am offered
financial awards to influence my decision, I will immediately report the situation to the Administrator’s office of the Bureau. I realize
that evaluations performed for the Bureau are paid according to a published fee schedule.
I have provided complete and accurate information on this application. I will immediately notify the MIR Program and provide a
copy of the charges or final order should any of the following situations occur:
1.
Any temporary or permanent probation, suspension, revocation, or limitation is placed on my license to practice by any court,
board, or administrative agency;
2.
I am charged with any crime, gross misdemeanor, felony, or violation of statutes or rules by any administrative agency, court,
or board;
3.
I am convicted of any crime, gross misdemeanor, felony or violation of statutes or rules by any administrative agency, court,
or board.
4.
Any event reportable to the National Practitioner Database.
I understand that:
It is my responsibility to inform the MIR Program in writing if there is any change in the status of my practice or
license and of any current or completed action of any nature.
The privilege of continuing as an MIR physician is not guaranteed.
If approved, I may be removed from the Registry at any time on the basis of factors including, but not limited to:
A misrepresentation on the “Application for Appointment to the Medical Impairment Rating (MIR)
Registry”;
Failure to report prior involvement or conflict of interest in a case assignment;
Refusal and/or substantial failure to comply with the provisions of the Rules of procedure including repeated
failure to determine impairment ratings correctly using the AMA Guides, as determined by the Medical
Director;
Inability to maintain the requirements of the Rules as determined by the Program Coordinator; or
I have included a copy of my curriculum vitae, medical license, proof of malpractice insurance, medical board certification
and proof of attendance at an approved medical impairment rating course.
___________________________________
___________________
Signature
Date
LB-0928 (REV 11/15)
RDA 10183
2
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