Tennessee Medical Panel (English)

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 indicate 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.

TO BE COMPLETED BY THE EMPLOYER:

Employee Name: *

Date Panel Provided: *

Employer: *

Date Of Injury:

Employer Contact:

Phone:

Email:

Physician 1

Name:

Phone:

Address:

City:

State:

Zip:

Is Telehealth available with Physician #1?:

Yes

If yes, web address:

Physician 2

Name:

Phone:

Address:

City:

State:

Zip:

Is Telehealth available with Physician #2?:

Yes

If yes, web address:

Physician 3

Name:

Phone:

Address:

City:

State:

Zip:

Is Telehealth available with Physician #3?:

Yes

If yes, web address:

(Optional) Telehealth-Only Physician 4

Name:

Phone:

Telehealth Provider email address:

Web Address:

TO BE COMPLETED BY THE EMPLOYEE:

I have selected the following physician from the list provided to me by my employer:

Physician Name:

App Date/Time:

I select:

In-person treatment

Treatment by Telehealth

Were you offered in-person treatment?:

Yes

Signature*

Date

Please sign your name above and save signature, and then submit the form below.

Download Form

Print Form