Tennessee > Workers Compensation
Employees Choice Of Physician C-42 - Tennessee
| Employees Choice Of Physician Form. This is a Tennessee form and can be used in Workers Compensation . |
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FORM C-42 TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT Division of Workers' Compensation Nashville, Tennessee 37243-0661 Website: www.state.tn.us/labor-wfd/wcomp.html 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: __________________________________ Employee: ________________________________________ Employer: ________________________________________ Date of Injury: ____________________________ SSN: ___________________________________ FEIN: __________________________________ Address: __________________________________ City: ___________________ State: ________ Zip: _______ 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: __________________________________________ Is Physician a Specialist? Yes Phone: _________________________ Address: __________________________________ City: ___________________ State: ________ Zip: _______ No If yes, give specialty: Ortho, Neuro, Chiro, etc. _____________________ Phone: _________________________ Physicians Name: __________________________________________ Is Physician a Specialist? Yes Address: __________________________________ City: ___________________ State: ________ Zip: _______ No If yes, give specialty: Ortho, Neuro, Chiro, etc. _____________________ Phone: _________________________ Physicians Name: __________________________________________ Is Physician a Specialist? Yes Address: __________________________________ City: ___________________ State: ________ Zip: _______ No If yes, give specialty: Ortho, Neuro, Chiro, etc. _____________________ Phone: _________________________ Physicians Name: __________________________________________ Is Physician a Specialist? Yes Address: __________________________________ City: ___________________ State: ________ Zip: _______ No If yes, give specialty: Ortho, Neuro, Chiro, etc. _____________________ Phone: _________________________ Physicians Name: __________________________________________ Is Physician a Specialist? Yes Address: __________________________________ City: ___________________ State: ________ Zip: _______ 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 ยง50-6-204. LB-0382 (rev. 8/05) American LegalNet, Inc. www.USCourtForms.com
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