Form C-42: Tennessee Employee’s Choice of Physician Medical Panel

Form C-42 PDF Details

The form has two parts: to be completed by the employer, and to be completed by the employee.

Employer, records: Keep the completed, signed version of this form on file and send a copy to the employee for their records.

Employer, State: Do not send this form to the State unless requested.

Employee, choice: Fill out the bottom portion of this form to indicate which physician you choose.

Employee, benefits: If you refuse to accept medical services from the chosen physician, your rights to benefits may be delayed.

Employee, send: Send completed form back to your employer.