Medical Impairment Rating (MIR) Medical Waiver And Consent {LB-0929}

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, (Printed name) , having filed a claim for workers' compensation benefits, do 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) American LegalNet, Inc. www.FormsWorkFlow.com RDA 10183