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. 1. _______________________________________ __________________________________ PHYSICIAN’S NAME PHONE ___________________________________________________________________________________________________________________ OFFICE ADDRESS CITY STATE ZIP 2. _______________________________________ __________________________________ PHYSICIAN’S NAME PHONE ___________________________________________________________________________________________________________________ OFFICE ADDRESS CITY STATE ZIP 3. _______________________________________ __________________________________ PHYSICIAN’S NAME PHONE ___________________________________________________________________________________________________________________ CITY STATE ZIP OFFICE ADDRESS 4. _______________________________________ __________________________________ PHYSICIAN’S or CHIROPRACTOR’S NAME PHONE ___________________________________________________________________________________________________________________ CITY STATE ZIP OFFICE ADDRESS 5. _______________________________________ __________________________________ PHYSICIAN’S NAME PHONE ___________________________________________________________________________________________________________________ CITY STATE ZIP OFFICE ADDRESS (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: _____________________ ___________________________________________________ Employer’s Name ___________________________________________ Employee’s Name _________________________________________________________ ______________________________________________ Street Address Street Address _________________________________________________________ City State Zip _________________________________________________________ Phone _________________________________________________________ Employer’s Signature ________________________________________________ City State Zip ________________________________________________ Phone ________________________________________________ Employee’s Signature _________________________________________________ Employee’s SSN _________________________________________________ State File Number LB-0382 (REV. 07/08) RDA 10183 American LegalNet, Inc. www.FormsWorkflow.com