Physician Application For Appointment To The Medical Impairment Rating (Mir) Registry Form (Page 2 of 2) in pdf

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:

Any temporary or permanent probation, suspension, revocation, or limitation is placed on my license to practice by any court,

board, or administrative agency;

I am charged with any crime, gross misdemeanor, felony, or violation of statutes or rules by any administrative agency, court,

or board;

I am convicted of any crime, gross misdemeanor, felony or violation of statutes or rules by any administrative agency, court,

or board.

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

Physician Application For Appointment To The Medical Impairment Rating (Mir) Registry Form Page 2

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