Form c 42 2026

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The document is Form C-42 from the Tennessee Department of Labor and Workforce Development, outlining the Agreement Between Employer/Employee Choice of Physician in compliance with Tennessee Workers' Compensation Law. It details the process for injured employees to select their treating physician, the employer's responsibilities in providing a list of physicians, and the conditions under which medical examinations and referrals must occur. The form also includes legal warnings regarding false information and penalties for fraud.

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Click ‘Get Form’ to open it in the editor.
Begin by entering the physician's name, telephone number, and office address in the designated fields. Ensure accuracy as this information is crucial for your medical treatment.
Continue filling out the remaining sections for additional physicians if necessary. You can list up to five physicians or chiropractors as per your employer's provided panel.
Select your chosen physician from the list and enter the date of selection, along with the date of injury and appointment.
Complete the employer and employee details, including names, addresses, and signatures. Make sure all information is correct to avoid any issues with your workers' compensation claim.

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