Can this be e-signed?

Yes. Electronic signatures are legally valid under the ESIGN Act (15 U.S.C. ch. 96) and UETA where adopted. Ensure the signer consents to electronic records, the platform captures an audit trail, and any ESIGN consumer disclosures are provided when required.

Is notarization required?

Not typically required for employer–employee physician selection agreements in Tennessee, but employers or carriers may request notarization. If notarization is required, confirm whether remote online notarization (RON) is accepted in the relevant state and follow notary rules.

What about HIPAA protections?

When the agreement contains protected health information, use a HIPAA-compliant platform and execute a Business Associate Agreement with any vendor accessing PHI. Retain authorizations consistent with 45 CFR §164.530(j) and restrict access to authorized personnel.

Who must sign the agreement?

The employee and an authorized employer representative should sign and date the form. Include printed names and titles; if an agent signs, document the scope of their authority to bind the employer or employee.

How long should I retain the signed form?

Retain the signed agreement for the active term plus applicable post-termination periods; maintain records for at least three years for tax and claims purposes and six years for HIPAA-related records.

How do parties change the selected physician?

Change the selection by executing a dated amendment signed by both parties or by creating a new agreement. Record the effective date and distribute updated copies to HR and claims administrators to prevent billing or authorization disputes.

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Tennessee Agreement Between Employer/Employee Choice of Physician

Tennessee Agreement Between Employer/Employee Choice of Physician

This template is fully customizable. Edit the text, fill out the fields, and send it for signature. Give it a try!

What this Tennessee choice-of-physician agreement is and when it applies

The Tennessee Agreement Between Employer/Employee Choice of Physician is a written record used in workplace injury and workers' compensation contexts to document which party may choose the treating physician. It identifies the selected medical provider, contact details, effective date, and any limitations on selection or referrals. The form clarifies authorization for care, assists claims administrators and medical billing, and creates an audit trail. Where allowed by law, the agreement may be executed electronically to speed treatment authorization and reduce administrative disputes.

Why documenting physician choice matters for employers and employees

This agreement eliminates ambiguity about who designates the treating physician, speeds access to approved care, and creates a concise record for claims handling, medical billing, and compliance with Tennessee workplace injury processes.

Who typically completes and relies on this form

Employers, HR teams, occupational health coordinators, and employees use this agreement when workplace injuries require designation of medical care.

Employers: document authorized providers for occupational injury claims and reduce treatment disputes.
Employees: confirm where to receive care and understand employer payment obligations for work-related treatment.
Claims administrators: rely on the agreement to validate provider authorization and streamline reimbursements.

Keep a signed copy with personnel and claims files to support treatment authorization and audit trails.

Step-by-step: completing and recording the agreement

Follow these steps to complete, sign, and file the Tennessee Agreement Between Employer/Employee Choice of Physician accurately and promptly.

01

Prepare Form: Confirm parties, employer details, and chosen physician information before filling.
02

Complete Fields: Enter legal names, addresses, effective date, and TIN where required.
03

Sign & Date: Obtain signatures from authorized employer rep and the employee with dates.
04

Store Copy: Provide copies to employee, employer file, and claims administrator.

Configuring a digital workflow for this agreement

Configure digital workflow fields and routing to match Tennessee notice and consent requirements for healthcare-related forms.

Field	Configuration
Signer Sequence	Employee signs first; employer or HR approves second.
Authentication	Email link with optional SMS code for higher assurance.
Conditional Fields	Show clinic NPI only if physician checkbox selected.
Retention Settings	Store completed PDF with audit trail for at least six years.

Platform and file requirements for secure electronic execution

Confirm platform supports PDF, audit trail, and TLS encryption, and can attach HIPAA consent addenda where required.

File Types: PDF, DOCX, and image support
Security: TLS 1.2/1.3 in transit, AES-256 at rest
Integrations: Salesforce, NetSuite, Google Workspace supported

How the electronic signing process works in practice

Digital signing workflow from upload to completed record, including authentication and automated audit trail capture.

Upload: Sender uploads completed agreement to the signing platform.
Assign Fields: Place signature, initials, and date fields for each signer.
Authenticate: Signers confirm identity via email link or SMS code.
Complete: System issues signed copy and audit certificate to all parties.

Essential sections to include in a professional agreement

Core sections commonly included in a professional Tennessee Agreement Between Employer/Employee Choice of Physician cover identification, selection process, consent, billing, duration, and amendment procedures.

Parties

Identify the employee and employer by full legal name, job title, employer unit, and contact details; include employer EIN and HR contact for claims routing and verification.

Physician

Record the selected physician's name, practice name, address, telephone, and National Provider Identifier (NPI) to ensure proper referrals, billing, and communication with the treating clinician.

Selection Terms

Specify whether employer or employee has selection authority, any limitations or rotation rules, and the effective date and duration of the physician designation.

Treatment Authorization

Clarify what treatments are authorized without additional approvals, whether preauthorization is needed for specialists, and how emergent care is handled.

Billing & Payments

Note who accepts responsibility for medical billing, procedure codes to anticipate, and instructions for submitting claims to workers' compensation carriers.

Amendment

Describe how changes to the physician selection are made, notice requirements, and signatures needed to effect a valid amendment.

Security and compliance features to verify

Encryption: TLS 1.2/1.3 in transit; AES-256 at rest.

Certifications: SOC 2 Type II, ISO 27001, PCI DSS.

HIPAA: BAA available for covered entities.

ESIGN/UETA: Complies with ESIGN and UETA standards.

Audit Trail: Detailed timestamps, IP, signer actions.

Access Controls: Role-based permissions and SSO support.

Key penalties and risks of incorrect or missing agreements

Claim Delays: Treatment and reimbursement may be delayed.

Incorrect Provider: Non-authorized care may be denied payment.

IRS Penalties: Backup withholding or reporting issues.

I-9 Violations: Paperwork errors risk fines $281–$2,789.

Legal Disputes: Contract ambiguity increases litigation risk.

HIPAA Breach: Unauthorized PHI sharing triggers penalties.

Common preparation mistakes to avoid

Failing to include the physician's full contact details causes referral and billing delays and can invalidate authorization for specialist care.
Using ambiguous language about selection authority creates disputes between employer and employee and may lead to delayed approvals and claim denials.
Missing signatures or dates makes the agreement unenforceable and can prevent claims from being accepted by carriers or delay treatment reimbursement.
Not recording effective dates or termination provisions can cause confusion about which provider is authorized at claim time and lead to billing disputes.

Timing considerations and filing expectations

Key deadlines and timing expectations for executing and using the Tennessee Agreement Between Employer/Employee Choice of Physician in relation to treatment and claims filing.

Execution Timing:

Sign as soon as treatment decision is made; prior to first non-emergency visit.

Claims Filing:

Provide signed agreement to claims administrator within set carrier timelines.

Effective Date:

Agreement's effective date governs authorized treatment start.

Amendments:

Amendments should be dated and re-signed by both parties.

Record Retention:

Maintain a copy in personnel and claims files for required retention periods.

Milestone timeline from execution to retention

Sequential milestones from agreement execution to claims processing and retention, showing where approvals and documentation are required.

01

Draft & Review

Complete fields and verify provider contact information before signatures.

02

Signatures Collected

Employee and authorized employer representative sign and date the document.

03

Distribute Copies

Send copies to employee, HR, and claims administrator immediately after signing.

04

Store & Retain

File completed record with audit trail per retention requirements.

Representative eSignature pricing and capability snapshot (signNow listed first)

A compact comparison of starting prices and key capability indicators for common eSignature providers; confirm vendor details before purchase.

	signNow	DocuSign	Adobe Sign	PandaDoc	HelloSign
Starting Price	$8/user/mo	$15/user/mo	$14/user/mo	$19/user/mo	$15/user/mo
Free Trial	7-day free trial	Verify	Verify	Verify	Verify
Bulk Send	Yes	Verify	Verify	Verify	Verify
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes	Yes	Yes	No	No
Envelope Cap	No cap	100 envelopes/user/year	Verify	Verify	Verify

Frequently asked questions about completing and submitting the agreement

Common questions and concise answers for completing, signing, authenticating, and retaining the Tennessee Agreement Between Employer/Employee Choice of Physician.

Need help? Contact support

Can this be e-signed?
Yes. Electronic signatures are legally valid under the ESIGN Act (15 U.S.C. ch. 96) and UETA where adopted. Ensure the signer consents to electronic records, the platform captures an audit trail, and any ESIGN consumer disclosures are provided when required.
Is notarization required?
Not typically required for employer–employee physician selection agreements in Tennessee, but employers or carriers may request notarization. If notarization is required, confirm whether remote online notarization (RON) is accepted in the relevant state and follow notary rules.
What about HIPAA protections?
When the agreement contains protected health information, use a HIPAA-compliant platform and execute a Business Associate Agreement with any vendor accessing PHI. Retain authorizations consistent with 45 CFR §164.530(j) and restrict access to authorized personnel.
Who must sign the agreement?
The employee and an authorized employer representative should sign and date the form. Include printed names and titles; if an agent signs, document the scope of their authority to bind the employer or employee.
How long should I retain the signed form?
Retain the signed agreement for the active term plus applicable post-termination periods; maintain records for at least three years for tax and claims purposes and six years for HIPAA-related records.
How do parties change the selected physician?
Change the selection by executing a dated amendment signed by both parties or by creating a new agreement. Record the effective date and distribute updated copies to HR and claims administrators to prevent billing or authorization disputes.

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