Form C-42 - Employee'S Choice Of Physician
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1FORM C-42
TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT
Division of Workers' Compensation
Nashville, Tennessee 37243-0661
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.
State File Number: __________________________________ Date of Injury: ____________________________
Employee: ________________________________________ SSN: ___________________________________
Address: __________________________________ City: ___________________ State: ________ Zip:_______
Employer: ________________________________________ FEIN: __________________________________
Address: __________________________________ City: ___________________ State: ________ Zip:_______
PANEL OF PHYSICIANS
A panel of three physicians is required. If the injury is a back injury the panel must be expanded to four, one of
whom must be a chiropractor. Chiropractor visits may be authorized for up to twelve (12) visits per back injury.
More than twelve (12) visits to such doctor of chiropractic must be specifically approved by the employer or
insurance carrier. The injured employee must select a physician (or chiropractor) from the panel.
Physicians Name: __________________________________________ Phone: _________________________
Address: __________________________________ City: ___________________ State: ________ Zip:_______
Is Physician a Specialist? Yes No If yes, give specialty: Ortho, Neuro, Chiro, etc. _____________________
Physicians Name: __________________________________________ Phone: _________________________
Address: __________________________________ City: ___________________ State: ________ Zip:_______
Is Physician a Specialist? Yes No If yes, give specialty: Ortho, Neuro, Chiro, etc. _____________________
Physicians Name: __________________________________________ Phone: _________________________
Address: __________________________________ City: ___________________ State: ________ Zip:_______
Is Physician a Specialist? Yes No If yes, give specialty: Ortho, Neuro, Chiro, etc. _____________________
Physicians Name: __________________________________________ Phone: _________________________
Address: __________________________________ City: ___________________ State: ________ Zip:_______
Is Physician a Specialist? Yes No If yes, give specialty: Ortho, Neuro, Chiro, etc. _____________________
Physicians Name: __________________________________________ Phone: _________________________
Address: __________________________________ City: ___________________ State: ________ Zip:_______
Is Physician a Specialist? Yes No If yes, give specialty: Ortho, Neuro, Chiro, 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. 8/05)
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