Tennessee Agreement Between Employer Or Employee Choice of Physician

FORM C-42
TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT
Division of Workers' Compensation
220 French Landing Dr.
Nashville, Tennessee 37243-1002
AGREEMENT BETWEEN EMPLOYER/EMPLOYEE CHOICE OF PHYSICIAN
It is a crime to knowingly provide false, incomplete or misleading information to any party to a workers' compensation transaction for the
purpose of committing fraud. Penalties include imprisonment, fines and denial of insurance benefits.
In compliance with The Tennessee Workers' Compensation Law, T.C.A. Section 50-6-204
The injured employee shall accept the medical benefits afforded hereunder; provided, the employer shall designate a group of three (3)
or more reputable physicians or surgeons not associated together in practice, if available in that community, from which the injured employee
shall have the privilege of selecting the operating surgeon and the attending physician. If the injury is a back injury, the statutory panel must be
expanded to 4, one of whom must be a chiropractor with treatment limited to 12 chiropractic visits. Further, if the injury or illness requires the
treatment of a physician or surgeon who practices orthopedic or neuroscience medicine, the employer may appoint a panel practicing orthopedic
or neuroscience medicine consisting of 5 physicians, with no more than 4 physicians affiliated in practice. If the employer provides this panel,
the injured employee shall be entitled to have a second opinion on the issue of surgery, impairment, and a diagnosis from that same panel.
1.
_______________________________________
__________________________________
PHYSICIAN’S NAME
PHONE
___________________________________________________________________________________________________________________
OFFICE ADDRESS
CITY
STATE
ZIP
2.
_______________________________________
__________________________________
PHYSICIAN’S NAME
PHONE
___________________________________________________________________________________________________________________
OFFICE ADDRESS
CITY
STATE
ZIP
3.
_______________________________________
__________________________________
PHYSICIAN’S NAME
PHONE
___________________________________________________________________________________________________________________
CITY
STATE
ZIP
OFFICE ADDRESS
4.
_______________________________________
__________________________________
PHYSICIAN’S or CHIROPRACTOR’S NAME
PHONE
___________________________________________________________________________________________________________________
CITY
STATE
ZIP
OFFICE ADDRESS
5.
_______________________________________
__________________________________
PHYSICIAN’S NAME
PHONE
___________________________________________________________________________________________________________________
CITY
STATE
ZIP
OFFICE ADDRESS
(d)(1) "The injured employee must submit to examination by the employer's physician at all reasonable times if requested to do so by the
employer, but the employee shall have the right to have the employee's own physician present at such examination, in which case the employee
shall be liable to such physician for such physician's services."
(7)
"If the injured employee refuses to comply with any reasonable request for examination or to accept the medical or specialized medical
services which the employer is required to furnish under the provisions of this law, such injured employee's right to compensation shall be
suspended and no compensation shall be due and payable while such injured employee continues such refusal."
According to the provisions of this agreement, I hereby have selected the following physician from the
list provided to me by my employer.
Physician chosen: _________________________________
Date of injury: __________________________
Date of selection: __________________________________
Date of appointment: _____________________
___________________________________________________
Employer’s Name
___________________________________________
Employee’s Name
_________________________________________________________
______________________________________________
Street Address
Street Address
_________________________________________________________
City
State
Zip
_________________________________________________________
Phone
________________________________________________
City
State
Zip
________________________________________________
Phone
_________________________________________________________
Employer’s Signature
________________________________________________
Employee’s Signature
_________________________________________________
Employee’s SSN
_________________________________________________
State File Number
CLEAR FORM
LB-0382 (REV. 07/08)
RDA 10183