Fill and Sign the Tennessee Employer Form

1 .      2                                                                   3       4                                                                   Physician chosen:       Date of selection:       Date of injury:       Date of appointment:                                                                                Date of treatment:       FORM C-42 TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT Division of Workers' Compensation Nashville, Tennessee 37243-0661 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(4) ''The injured employee shall accept the medical benefits afforded hereunder; provided, that the employer shall that community, from which the injured employee shall have the privilege of selecting the operating designate a group of three (3) or more reputable physicians or surgeons not associated together in practice, if available in surgeon or the attending physician and, provided further, that the liability of the employer for such services rendered the employeebe limited to such charges as prevail for similar treatment in the community where the injured employee resides. shall The above listing of physicians or surgeons may include doctors of chiropractic within the scope of their licenses.'' PHYSICIAN'S NAME PHYSICIAN'S NAME STREET ADDRESS STREET ADDRESS CITY STATE ZIP CITY STATE ZIP PHONE PHONE PHYSICIAN'S NAME PHYSICIAN'S NAME-ALTERNATE CHOICE STREET ADDRESS STREET ADDRESS CITY STATE ZIP CITY STATE ZIP PHONE PHONE (d)(1) ''The injured employee must submit himself to the 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 or examination or to accept the medical or specialized medical services which the employer is required to furnish under the provisions of this law, such injuredemployee's right to compensation shall be suspended and no compensation shall be due and payable while such injuredemployee 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. EMPLOYER'S NAME EMPLOYEE'S NAME STREET ADDRESS STREET ADDRESS CITY STATE ZIP CITY STATE ZIP PHONE PHONE EMPLOYER'S SIGNATURE EMPLOYEE'S SIGNATURE Physician's signature: LB-0382 (rev. 8/99)