The Tennessee C 42 form is an agreement between an employer and an employee regarding the choice of physician for workers' compensation claims. This form outlines the rights and responsibilities of both parties when it comes to selecting medical providers after an injury. Understanding this form is crucial for ensuring proper medical treatment and compliance with Tennessee's workers' compensation laws.
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The Tennessee C 42 form plays a crucial role in the workers' compensation process, specifically concerning the choice of physician for injured employees. This form is utilized to document an agreement between the employer and the employee regarding the selection of medical professionals who will provide necessary treatment following a workplace injury. Under Tennessee law, employers are required to offer a panel of at least three reputable physicians or surgeons, ensuring that these medical practitioners are not associated in practice. This allows injured employees to choose their attending physician and operating surgeon from a diverse group. In cases of back injuries, the panel must include a chiropractor and expand to four physicians. Additionally, if specialized treatment is needed, such as orthopedic or neuroscience care, employers may provide a panel of five physicians, with specific guidelines on affiliations. It is essential for injured employees to understand their rights and responsibilities under this agreement, including the requirement to attend medical examinations requested by the employer. Failure to comply with these requests can result in the suspension of compensation benefits. The form also requires the employee to select a physician from the provided list, ensuring that they receive appropriate medical care tailored to their needs.
FORM C-42
TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT
Division of Workers' Compensation
220 French Landing Dr.
Nashville, Tennessee 37243-1002
AGREEMENT BETWEEN EMPLOYER/EMPLOYEE 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.
In compliance with The Tennessee Workers' Compensation Law, T.C.A. Section 50-6-204
The injured employee shall accept the medical benefits afforded hereunder; provided, the employer shall designate a group of three (3) or more reputable physicians or surgeons not associated together in practice, if available in that community, from which the injured employee shall have the privilege of selecting the operating surgeon and the attending physician. If the injury is a back injury, the statutory panel must be expanded to 4, one of whom must be a chiropractor with treatment limited to 12 chiropractic visits. Further, if the injury or illness requires the treatment of a physician or surgeon who practices orthopedic or neuroscience medicine, the employer may appoint a panel practicing orthopedic or neuroscience medicine consisting of 5 physicians, with no more than 4 physicians affiliated in practice. If the employer provides this panel, the injured employee shall be entitled to have a second opinion on the issue of surgery, impairment, and a diagnosis from that same panel.
James G. Stensby, MD
931-967-5646
Physician’s Name
Phone
186 Hospital Road
Winchester
TN
37398
Office Address
City
State
Zip
Lynn J. Williams, MD
931-962-0561
2006 Decherd Blvd.
Decherd
37324
Ephraim B. Gammada, MD
931-962-1004
1509 Old Cowan Road
(d)(1) "The injured employee must submit to examination by the employer's physician at all reasonable times if requested to do so by the employer, but the employee shall have the right to have the employee's own physician present at such examination, in which case the employee shall be liable to such physician for such physician's services."
(7)"If the injured employee refuses to comply with any reasonable request for examination or to accept the medical or specialized medical services which the employer is required to furnish under the provisions of this law, such injured employee's right to compensation shall be suspended and no compensation shall be due and payable while such injured employee continues such refusal."
According to the provisions of this agreement, I hereby have selected the following physician from the list provided to me by my employer.
Physician chosen:__________________________
Date of injury:_____________________
Date of selection:__________________________
Date of appointment:________________
University of the South
________________________________________________
735 University Avenue
Employee’s Name
Sewanee, TN 37383
931-598-1381
Employee’s Address
Employee’s Phone
Employee’s Signature
_______________________________
Employer’s Signature
Employee’s SSN
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