Fill and Sign the Sedgwick Claims Kit Tennessee Uscom Form

LB-0382 (REV 11/15) RDA 10183 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: Physi cian Name ___________ ___________________________________________ Date Select ed ____________________________ Employee Name ______________________________________________________ Appt Date/Time _______________ ___________ Address _________________________________________ City ___________________________ State ______ Zip _____________ Phone _________________________________________ Email _______________________________________________________ Emplo yee Signature _________________________________________________________ Date _____________________________