Roane County Government

FORM C-42

Tennessee Bureau of Workers' Compensation
Employee's Choice of Physician - Medical Panel
Employer
- List at least three physicians and provide this panel to employee upon the report of a workplace injury.
- Keep the completed original form on file and send a copy to the employee for their records.
  - Do not send this form to the State unless requested.
Employee
- Fill out the bottom portion of this form to indicated 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.
- Send completed form back to your employer.
Employee Name*
Date Panel Provided*

MonthDayYear
Date
Date of Injury*

MonthDayYear
Date
TO BE COMPLETED BY THE EMPLOYEE:
I have selected the following physician from the list provided to me by my employer:
Physician Name:*
Appt Date/Time:
I select:*

In-person treatmentTreatment by Telehealth
Were you offered in-person treatment?*

YesNo
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

FORM C-42