C-42 Form. If you refuse to accept medical services from the chosen physician, your rights to benefits may be delayed. Web employee fill out the bottom portion of this form to indicate which physician you choose.
Form 42A765GP(K)
If you refuse to accept medical services from the chosen physician, your rights to benefits may be delayed. Web employee fill out the bottom portion of this form to indicate which physician you choose. Any business or employer that wants to grant an individual or service company. Web written authorization may be revoked by grantor or grantee. Alternative versions of the form are not allowed. Individuals may receive, review and correct information that twc collects about the individual by emailing to open.records@twc.state.tx.us. Keep the completed form on file and send a copy to the employee for their records.
Individuals may receive, review and correct information that twc collects about the individual by emailing to open.records@twc.state.tx.us. If you refuse to accept medical services from the chosen physician, your rights to benefits may be delayed. Web employee fill out the bottom portion of this form to indicate which physician you choose. Any business or employer that wants to grant an individual or service company. Individuals may receive, review and correct information that twc collects about the individual by emailing to open.records@twc.state.tx.us. Web written authorization may be revoked by grantor or grantee. Keep the completed form on file and send a copy to the employee for their records. Alternative versions of the form are not allowed.
