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Form C-42 - Employee'S Choice Of Physician

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Tennessee Bureau of Workers’ Compensation

220 French Landing Drive, I-B

Nashville, TN 37243-1002

FORM C-42

EMPLOYEE’S CHOICE OF PHYSICIAN

An employer must provide a partially-completed form listing at least three physicians to an employee upon the

report of a workplace injury. The employee must complete and then sign and date the section below that indicates the

physician chosen. A copy of the fully-completed form should be provided to the employee with the original kept on file

by the employer. If the employee refuses to accept medical services from the chosen physician, the employee’s rights to

benefits may be delayed. NOTE: Employees traveling more than 15 miles one way to or from medical treatment may

seek reimbursement of their travel expenses from the insurance carrier.

TO BE COMPLETED BY THE EMPLOYER:

Employer __________________________________________________________________ Date of Injury _____________________

Employer Contact ____________________________________ Phone _________________ Email ____________________________

Physician Name _____________________________________________________ Phone ___________________________________

Address _________________________________________ City ___________________________ State ______ Zip _____________

Physician Name _____________________________________________________ Phone ___________________________________

Address _________________________________________ City ___________________________ State ______ Zip _____________

Physician Name _____________________________________________________ Phone ___________________________________

Address _________________________________________ City ___________________________ State ______ Zip _____________

TO BE COMPLETED BY THE EMPLOYEE:

I have selected the following physician from the list provided to me by my employer:

Physician Name ______________________________________________________ Date Selected ____________________________

Employee Name ______________________________________________________ Appt Date/Time __________________________

Address _________________________________________ City ___________________________ State ______ Zip _____________

Phone _________________________________________ Email _______________________________________________________

Employee Signature _________________________________________________________ Date _____________________________

LB-0382 (REV 11/15)

RDA 10183

Form C-42 - Employee'S Choice Of Physician

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