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