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Tennessee LB-0931: MIR Report, AMA Guides 5th Edition

When the impairment rating is the only disputed issue in a Tennessee workers' compensation claim, either party can request an independent rating from a physician on the Bureau's Medical Impairment Rating (MIR) Registry. For injuries before January 1, 2008, the MIR physician reports on this 10-page form using the AMA Guides, 5th edition. MIR reports are legally presumed accurate and usually supersede other rating opinions.

Who completes it

The MIR Registry physician completes every section, from examinee history through the impairment rating, and signs the certification. The parties do not complete any part of the report.

Submitting and payment

How to submit it
Return the completed report with all required attachments to the Bureau's MIR Registry by overnight delivery; the Bureau sends it for peer review and distributes it to the parties.
Who pays
The employer bears the cost of the MIR evaluation, regardless of which party requested it.

Good to know

  • Sections run from patient and physician information through history, physical exam, chronological treatment history, record review, surgeries, impairment and the physician's certification.
  • For each imaging study or EMG reviewed, state the dates and whether the actual images or only the written report were reviewed.
  • The rating discussion must address inconsistencies in the exam, the rationale for the rating, and why this rating is correct and at least one other physician's rating is not.
  • Registry physicians must hold an unrestricted Tennessee license, ABMS board certification, an approved AMA Guides training course and malpractice coverage.

Get the official form

Download the current version from the source each time; forms change without notice.

Medical Impairment Rating (MIR) Report AMA Guides, 5th Edition

Official pagePDF

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How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.

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Frequently asked questions

When is the 5th edition MIR report used in Tennessee?

The Bureau's MIR program page links the 5th edition report for injuries before January 1, 2008. Injuries on or after that date must be rated under the AMA Guides, 6th edition, on the LB-0931A form. The MIR program itself applies to injuries on or after July 1, 2005.

How much weight does an MIR report carry?

The Bureau states that MIR reports are legally presumed to be accurate and that a much higher standard of evidence is needed to refute one, so they usually supersede other impairment rating opinions. Each report also goes to another independent physician for peer review of the AMA Guides methodology.