Get Tn Lb-0930 2015-2026

Completing the TN LB-0930 form for a Medical Impairment Rating is crucial for ensuring your request is processed efficiently. This guide provides clear, step-by-step instructions to help you navigate the online form with confidence.

Follow the steps to complete the TN LB-0930 form online.

1. Press the ‘Get Form’ button to access the form and open it in your preferred online editor.
2. Indicate the requesting party by checking the appropriate box for employee, employer, or insurance carrier. Fill in the name of the person requesting the Medical Impairment Rating (MIR) and provide their contact information, including phone number and email address.
3. Specify the relationship to the requesting party, such as attorney, union representative, or family member. Enter the state file number, date of injury, and date of maximum medical improvement (MMI).
4. Complete the employee's details by providing their name, Social Security number (SSN), date of birth (DOB), home address, city, state, zip code, and phone number. If applicable, add the employee’s attorney's information and their practice name and address.
5. Fill in the employer's name, Federal Employer Identification Number (FEIN), and business address details. Ensure all fields are accurately completed.
6. Specify any body parts or conditions requiring an MIR evaluation. Check all relevant categories such as upper extremities, lower extremities, neck or back, and other specific body parts or systems.
7. Answer the questions regarding the involvement of a Workers’ Compensation specialist, whether a Benefit Review Conference has been requested, and if the Second Injury Fund is involved. Provide information about whether a C-42 form was issued.
8. List all physicians who have provided an impairment rating for the case, including their contact details, evaluated body parts, work-related diagnosis, and impairment rating in the designated table.
9. If applicable, provide the names and details of any treating physicians made available to the injured worker, as well as the names of all employer-paid and employee-paid treating physicians.
10. Review the informational summary that outlines the Workers’ Compensation Medical Impairment Rating process for clarity on next steps.
11. Finally, complete the certificate of mailing section by indicating the date of mailing and listing all parties copied, then sign the document as the requesting party.
12. Once all sections are completed, save your changes, and you may choose to download, print, or share the completed form as needed.

Complete your TN LB-0930 form online today to ensure your request is processed without delay.