State of Tennessee Department of Labor and Workforce Development Division of Workers' Compensation 220 French Landing Drive Nashville, Tennessee 37243-1002 1-800-332-2667 Fax: (615) 532-1468 GOVERNMENTAL ENTITIES AGREEMENT BETWEEN EMPLOYER/EMPLOYEE CHOICE OF PHYSICIAN FORM DATE: March 22, 2004 The Tennessee Workers' Compensation Division has developed an "Agreement Between Employer/Employee Choice of Physician" (C-42G) for use by governmental entities established by TCA§29-20-401 and self insured pools established by TCA§50-6-405(c)(1). It is mandatory to offer the injured employee a panel of three physicians. If you do not have a panel, call your insurance carrier and develop one. Post the panel so your employees will know who they are allowed to see if they are injured. The employee should be given a choice of three (3) physicians not associated together in practice. The list or panel of three physicians should be in or near the employee's community of residence. The employee has the privilege of choosing one physician from the list of three. The employee is then required to accept treatment from the chosen physician and should not see any other physician unless the chosen physician makes a referral. A signed "Agreement Between Employer/Employee Choice of Physician" (C-42G) is the employer's proof that the employee was offered a choice of physicians. A copy of this completed form must be provided to the employee. The employer must keep the original form on file and upon request provide a copy to the Division of Workers' Compensation. Please send an electronic request via electronic mail to WC.Info@state.tn.us to receive a copy of the "Agreement Between Employer/Employee Choice of Physician" (C-42G). SAH/pkp NOTICE American LegalNet, Inc. www.FormsWorkFlow.com