Form C-42g - Employee'S Choice Of Physician

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FORM C-42G
TENNESSEE DIVISION OF WORKERS’ COMPENSATION
Nashville, Tennessee 37243-1002
Website:
Telephone: 1-800-332-2667
EMPLOYEE’S 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.
THIS FORM IS ONLY FOR USE BY GOVERNMENTAL ENTITIES ESTABLISHED BY TCA§29-20-401
AND SELF INSURED POOLS ESTABLISHED BY TCA§50-6-405(c)(1).
State File Number: __________________________________
Date of Injury: ____________________________
Employee: ________________________________________
SSN: ___________________________________
Address: __________________________________ City: ___________________ State: ________ Zip: _______
Employer: ________________________________________
FEIN: __________________________________
Address: __________________________________ City: ___________________ State: ________ Zip: _______
PANEL OF PHYSICIANS
Tennessee Code Annotated §50-6-204 requires an employer to offer a panel of three physicians to the injured employee. The
injured employee must select a physician from the panel.
Physicians Name: __________________________________________
Phone: _________________________
Address: __________________________________ City: ___________________ State: ________ Zip: _______
Is Physician a Specialist?
Yes
No If yes, give specialty: Ortho, Neuro, etc. ___________________________
Physicians Name: __________________________________________
Phone: _________________________
Address: __________________________________ City: ___________________ State: ________ Zip: _______
Is Physician a Specialist?
Yes
No If yes, give specialty: Ortho, Neuro, etc. ___________________________
Physicians Name: __________________________________________
Phone: _________________________
Address: __________________________________ City: ___________________ State: ________ Zip: _______
Is Physician a Specialist?
Yes
No If yes, give specialty: Ortho, Neuro, etc. ___________________________
Physicians Name: __________________________________________
Phone: _________________________
Address: __________________________________ City: ___________________ State: ________ Zip: _______
Is Physician a Specialist?
Yes
No If yes, give specialty: Ortho, Neuro, etc. ___________________________
Physicians Name: __________________________________________
Phone: _________________________
Address: __________________________________ City: ___________________ State: ________ Zip: _______
Is Physician a Specialist?
Yes
No If yes, give specialty: Ortho, Neuro, etc. ___________________________
I hereby have selected the following physician from the list provided to me by my employer:
Physician Chosen: ______________________________________________________________________________
Employee Signature: ________________________________________ Date Selected: ________________________
A copy of this form must be provided to the employee. The employer must keep the original form on file
and upon request provide a copy to the Division of Workers’ Compensation.
This form is required to be in compliance with Tennessee Code Annotated §50-6-204.
LB-0382
(rev. 8/14)

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