Employee Choice Of Physician Form {C-42}

LB-0382 (REV 11/15) RDA 10183 Tennessee Bureau of Workers222 Compensation 220 French Landing Drive, I-B Nashville, TN 37243-1002 FORM C-42 EMPLOYEE222S 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 employee222s 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 American LegalNet, Inc. www.FormsWorkFlow.com