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Tennessee Bureau of Workers Compensation 220 French Landing Drive, IB Nashville, TN 372431002 FORM C42EMPLOYEES CHOICE OF PHYSICIAN An employer must provide a partiallycompleted form listing at least
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How to fill out tennessee-choice-of-physician-agreement-english
How to fill out tennessee-choice-of-physician-agreement-english
01
Obtain a copy of the Tennessee Choice of Physician Agreement form in English.
02
Fill in your personal information accurately, including your full name, address, and contact details.
03
Read and understand the terms and conditions of the agreement thoroughly before signing.
04
Choose a physician from the provided list and indicate your choice clearly on the form.
05
Sign and date the agreement to acknowledge your acceptance of the selected physician.
Who needs tennessee-choice-of-physician-agreement-english?
01
Individuals residing in Tennessee who wish to select a specific physician for medical treatment.
02
Employers in Tennessee who want to offer their employees the option to choose their own physician for work-related injuries.
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What is tennessee-choice-of-physician-agreement-english?
The Tennessee Choice of Physician Agreement is a document that allows an injured worker in Tennessee to select their own physician for medical treatment related to a work-related injury.
Who is required to file tennessee-choice-of-physician-agreement-english?
Both employers and injured workers are required to file the Tennessee Choice of Physician Agreement to ensure that the injured worker can receive medical treatment from their chosen physician.
How to fill out tennessee-choice-of-physician-agreement-english?
To fill out the Tennessee Choice of Physician Agreement, the injured worker must provide their personal information, the details of the injury, and the information of the chosen physician, then both the worker and employer must sign the form.
What is the purpose of tennessee-choice-of-physician-agreement-english?
The purpose of the Tennessee Choice of Physician Agreement is to give injured workers the right to choose their healthcare provider for treatment of work-related injuries while ensuring compliance with state regulations.
What information must be reported on tennessee-choice-of-physician-agreement-english?
The agreement must report the injured worker's name, the date of the injury, the nature of the injury, the chosen physician's name and contact information, and signatures from both the worker and employer.
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