Get Employee Choice Of Physician C 42g

This guide provides clear and comprehensive steps to assist you in completing the Employee Choice Of Physician C 42g form online. By following these instructions, you will ensure that all necessary information is accurately submitted.

Follow the steps to successfully complete the form online.

1. Click 'Get Form' button to obtain the form and open it in your editor.
2. Enter the state file number at the designated section. This number is unique to your case and needs to be filled out carefully.
3. Fill in the date of injury. Ensure the date is accurate, as it is crucial for your records.
4. Provide your name as the employee, followed by your Social Security Number (SSN). Keep this information confidential.
5. Complete your address details, including city, state, and ZIP code.
6. Enter your employer's name and their Federal Employer Identification Number (FEIN). Fill in the employer's address, including city, state, and ZIP code.
7. In the panel of physicians section, you will need to choose from the designated physicians listed. Fill in the name, phone number, and address for each physician.
8. Indicate whether each physician is a specialist, marking 'Yes' or 'No.' If yes, specify the specialty.
9. Once you have selected a physician from the list provided by your employer, write their name in the 'Physician Chosen' section.
10. Sign the form as the employee and enter the date you selected the physician.
11. After completing the form, ensure you save your changes, and download, print, or share the form as required.

Complete your documents online for a smooth submission process.