Download Tennessee C 42 Template in PDF Open Editor Here

Download Tennessee C 42 Template in PDF

The Tennessee C 42 form serves as an essential document for establishing an agreement between an employer and an employee regarding the choice of physician in workers' compensation cases. This form outlines the rights and responsibilities of both parties, ensuring that injured employees can select from a designated panel of physicians for their medical care. Understanding this form is crucial for navigating the complexities of workers' compensation in Tennessee.

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The Tennessee C 42 form is an important document that facilitates the relationship between employers and employees regarding medical care in the event of a workplace injury. This form is part of the Tennessee Workers' Compensation process and outlines the agreement on the choice of physician for injured employees. Employers must provide a panel of at least three reputable physicians or surgeons, ensuring that they are not affiliated in practice. In cases of back injuries, this panel expands to four, including a chiropractor, while orthopedic or neuroscience injuries may require a panel of five physicians. The form emphasizes the necessity for injured employees to accept medical benefits and submit to examinations by the employer's designated physician when requested. However, employees retain the right to have their own physician present during such examinations. Failure to comply with these requests can result in the suspension of compensation benefits. The form also requires employees to indicate their chosen physician from the provided list, along with essential details such as the date of injury and signatures from both the employee and employer. Understanding the Tennessee C 42 form is crucial for navigating the workers' compensation landscape effectively.

FAQ

  1. What is the purpose of the Tennessee C 42 form?

    The Tennessee C 42 form serves as an agreement between an employer and an injured employee regarding the selection of a physician for medical treatment following a workplace injury. This form ensures that the injured employee can choose from a designated panel of physicians, thereby facilitating access to necessary medical care while adhering to state workers' compensation laws.

  2. Who is responsible for providing the list of physicians?

    The employer is responsible for designating a group of three or more reputable physicians or surgeons from which the injured employee can select their medical provider. If the injury involves the back, the panel must include four physicians, one of whom must be a chiropractor.

  3. What happens if the employee refuses to see the employer's designated physician?

    If the injured employee refuses to comply with a reasonable request to see the employer's physician or to accept the medical services provided, their right to compensation may be suspended. This means that no compensation will be paid while the employee continues to refuse the required medical examination or treatment.

  4. Can the employee have their own physician present during the examination?

    Yes, the injured employee has the right to have their own physician present during any examination requested by the employer. However, the employee will be responsible for any fees charged by their own physician for this service.

  5. What should an employee do if they want a second opinion?

    If an employee wishes to obtain a second opinion regarding surgery, impairment, or diagnosis, they are entitled to do so from the same panel of physicians provided by the employer. This ensures that the employee has access to multiple perspectives on their medical condition.

  6. What information is required on the C 42 form?

    The C 42 form requires several key pieces of information, including the employee's name, address, phone number, the date of injury, the date of selection of the physician, and the date of appointment. Additionally, both the employee and employer must sign the form to validate the agreement.

  7. What are the consequences of providing false information on the C 42 form?

    Providing false, incomplete, or misleading information on the C 42 form is considered a crime. Penalties for such actions can include imprisonment, fines, and denial of insurance benefits. It is crucial for all parties to provide accurate information to avoid serious legal repercussions.

  8. How can an employee ensure they select the right physician?

    To ensure the right choice, an employee should review the list of designated physicians provided by their employer. They can consider factors such as the physician's specialty, location, and reputation. If necessary, the employee may also seek recommendations from trusted sources or consult their own healthcare provider for advice.

Common PDF Forms

Documents used along the form

When dealing with workers' compensation claims in Tennessee, several forms and documents complement the Tennessee C 42 form. Each of these documents plays a vital role in ensuring that both the employer and employee understand their rights and responsibilities. Below is a list of commonly used forms that may accompany the C 42.

  • Form C-40: This form is used to report an employee's injury to the Tennessee Department of Labor and Workforce Development. It outlines the details of the incident, including the nature of the injury and how it occurred.
  • Form C-41: The C-41 form is a notice of employee's rights and responsibilities under the Tennessee Workers' Compensation Law. It informs employees about their rights to medical treatment and compensation.
  • Ohio Living Will: To ensure your medical preferences are respected, it's important to familiarize yourself with the Ohio Living Will form, which is available for your use at Ohio Documents Online.
  • Form C-43: This document is a request for a panel of physicians. Employers must provide this panel to injured employees, allowing them to choose their medical provider from a list of qualified physicians.
  • Form C-44: The C-44 form serves as a notice of the employee's return to work. It must be submitted to confirm that the employee is fit to resume their job duties following an injury.
  • Form C-45: This form is used to report any changes in the employee's medical condition. It is essential for updating the employer and insurance carrier about the employee's recovery progress.
  • Form C-46: The C-46 form is a request for a hearing. If disputes arise regarding the workers' compensation claim, either party may use this form to seek a formal review of the case.

Understanding these forms can help streamline the workers' compensation process. Each document serves a specific purpose, contributing to the overall clarity and efficiency of managing claims. Proper completion and submission of these forms are crucial for both employees and employers in navigating the complexities of workers' compensation in Tennessee.