Physician Application For Appointment To The Medical Impairment Rating (Mir) Registry Form printable pdf download

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Have your hospital privileges in any state or country ever been modified or withdrawn?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

Physician Application For Appointment To The Medical Impairment Rating (Mir) Registry Form