In the realm of workplace injuries in Tennessee, navigating the recovery process can become a bit less daunting with the guidance provided by the Tennessee C 42 Form. This vital document, under the umbrella of The Tennessee Department of Labor and Workforce Development, plays a crucial role in ensuring that injured employees receive the medical attention they need through a structured pathway. It lays down the groundwork for choosing a physician from a pre-designated group provided by the employer, in compliance with the Tennessee Workers' Compensation Law, T.C.A. Section 50-6-204. Employees face the crucial step of selecting an attending physician or operating surgeon from a panel of three or more reputable physicians, or in specific cases, such as back injuries, this choice extends to a panel expanded to include a chiropractor. Beyond facilitating the initial selection, the form outlines provisions for further diagnostic opinions in specialized fields, such as orthopedic or neuroscience, if needed, by expanding the panel to five physicians. The emphasis on choice, coupled with stringent guidelines to curb misuse through false information, highlights the form's dual aim: to streamline the medical recovery journey for the injured and to uphold the integrity of the workers' compensation system. Reflecting a balance between employee rights and responsibilities, the document also addresses conditions under which refusal of treatment or examinations could lead to suspension of compensation benefits, thereby stressing the importance of compliance and cooperation from both parties.
| Question | Answer |
|---|---|
| Form Name | Tennessee Form C 42 |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | C-42, TENNESSEE, form c 42, false |
FORM
TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT
Division of Workers' Compensation
220 French Landing Dr.
Nashville, Tennessee
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
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.
James G. Stensby, MD |
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Physician’s Name |
Phone |
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186 Hospital Road |
Winchester |
TN |
37398 |
Office Address |
City |
State |
Zip |
Lynn J. Williams, MD |
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Physician’s Name |
Phone |
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2006 Decherd Blvd. |
Decherd |
TN |
37324 |
Office Address |
City |
State |
Zip |
Ephraim B. Gammada, MD |
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Physician’s Name |
Phone |
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1509 Old Cowan Road |
Winchester |
TN |
37398 |
Office Address |
City |
State |
Zip |
(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:________________ |
University of the South |
________________________________________________ |
735 University Avenue |
Employee’s Name |
Sewanee, TN 37383 |
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________________________________________________ |
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Employee’s Address |
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________________________________________________ |
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Employee’s Phone |
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________________________________________________ |
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Employee’s Signature |
_______________________________ |
________________________________________________ |
Employer’s Signature |
Employee’s SSN |