How to Fill Out Form C-42

Form C-42 at a glance

What it is: Form C-42 is the Employee's Choice of Physician Medical Panel of the Tennessee Bureau of Workers' Compensation.

Who signs: Sign on the Employee Signature line and enter the Date.

Employer: list at least three physicians and provide this panel to employee upon the report of a workplace injury.

A filled-in Form C-42 example: an employee picks a physician from the panel

Form C-42 example filled out, example: an employee picks a physician from the panel — Dana Sample chooses a physician on Form C-42 from the employer's panel. The employer listed three physicians, none offers telehealth, and Dana picks in-person treatment. The picture shows the filled form, and every value in it is made up. Each Telehealth available box is marked No, so every web address box stays empty. Telehealth-Only Physician 4 is optional, so Telehealth-Only Physician 4 stays empty. Treatment by Telehealth is left blank because Dana selects In-person treatment, and Dana was offered in-person treatment, so Yes is marked.

How to fill out Form C-42, box by box

Employee, employer and dates

To be completed by the employer: enter the Employee Name, the Date Panel Provided, the Employer and the Date of Injury.

Enter the Employer Contact, with the Phone and the Email.

Physician Option 1, 2 and 3

For each of Physician Option 1, 2 and 3, enter the Name, the Phone, the Address, the City, the State and the Zip, and mark Yes or No under Is Telehealth available?. If yes, enter the web address.

Telehealth-Only Physician 4

(Optional) For a Telehealth-Only Physician 4, enter the Name, the Phone, the Telehealth Provider email address and the Web address.

Physician Name and treatment

To be completed by the employee: enter the Physician Name after "I have selected the following physician from the list provided to me by my employer".

Mark In-person treatment or Treatment by Telehealth after "I select", and mark Yes or No under Were you offered in-person treatment?.

More rules for Form C-42

Employee: fill out the bottom portion of this form to indicate which physician you choose. If you refuse to accept medical services from the chosen physician, your rights to benefits may be delayed. Traveling more than 15 miles (one way) to (or from) medical treatment? Employees may seek reimbursement of their travel expenses from the insurance carrier.

Common questions about Form C-42

Where do I file it?

Employer: keep the completed, signed version of this form on file, send a copy to the employee for their records, and do not send this form to the State unless requested. Employee: send the completed form back to your employer.

Sources

[1] Form C-42 (LB-0382 REV 03/2026), Employee's Choice of Physician Medical Panel, Tennessee Bureau of Workers' Compensation (the Official source link on this page).

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.

Question	Answer
Form Name	Form C-42
Form Length	1 page
Fillable?	Yes
Fillable fields	45
Avg. time to fill out	8 min
Edition	03/2026
Issuing agency	Tennessee Bureau of Workers' Compensation
Who signs	The employee
Matches the agency's file	Yes, checked October 2, 2026
Other names	C-42, C42, C 42, Form C-42, Tennessee C-42, Employee's Choice of Physician, Medical Panel
Official source	Form C-42 (Rev 03/2026), Tennessee Bureau of Workers' Compensation

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