Tennessee Bureau of Workers’ Compensation
220 French Landing Drive, I-B
Nashville, TN 37243-1002
FORM C-42
EMPLOYEE’S CHOICE OF PHYSICIAN
An employer must provide a partially-completed form listing at least three physicians to an employee upon the
report of a workplace injury. The employee must complete and then sign and date the section below that indicates the
physician chosen. A copy of the fully-completed form should be provided to the employee with the original kept on file
by the employer. If the employee refuses to accept medical services from the chosen physician, the employee’s rights to
benefits may be delayed. NOTE: Employees traveling more than 15 miles one way to or from medical treatment may
seek reimbursement of their travel expenses from the insurance carrier.
TO BE COMPLETED BY THE EMPLOYER:
Employer __________________________________________________________________ Date of Injury _____________________
Employer Contact ____________________________________ Phone _________________ Email ____________________________
Physician Name _____________________________________________________ Phone ___________________________________
Address _________________________________________ City ___________________________ State ______ Zip _____________
Physician Name _____________________________________________________ Phone ___________________________________
Address _________________________________________ City ___________________________ State ______ Zip _____________
Physician Name _____________________________________________________ Phone ___________________________________
Address _________________________________________ City ___________________________ State ______ Zip _____________
TO BE COMPLETED BY THE EMPLOYEE:
I have selected the following physician from the list provided to me by my employer:
Physician Name ______________________________________________________ Date Selected ____________________________
Employee Name ______________________________________________________ Appt Date/Time __________________________
Address _________________________________________ City ___________________________ State ______ Zip _____________
Phone _________________________________________ Email _______________________________________________________
Employee Signature _________________________________________________________ Date _____________________________
LB-0382 (REV 11/15)
RDA 10183