PDF File: 1 page; Last revised November 23, 2009
Authorization for Release of Medical Records by a Hospital/Provider for the purpose of Administering a Connecticut Workers’ Compensation Claim for Benefits
The Authorization for Release of Medical Records form may be used by any hospital or provider for the purpose of administering a Connecticut workers’ compensation claim for benefits.
PDF File: 1 page; Last revised September 26, 2011
Workers' Compensation - Employee Medical & Work Status Form
The Workers' Compensation - Employee Medical & Work Status Form may be used by a physician to report an injured employee’s medical progress and work status to a payor requesting such information. A copy of the completed form must also be provided to the injured employee.
[NOTE: Also see the Payor and Medical Provider Guidelines publication, which describes the purpose and proper use of this form.]
PDF File: 1 page; Last revised September 3, 2010
Physician’s Permanent Impairment Evaluation
The Form 42 is to be completed by the examining licensed physician to report a claimant’s permanent partial loss or loss of use of a body part, as well as the likely date of the claimant’s maximum medical improvement.
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The Workers' Compensation Commission's recommendation of Adobe's free Adobe Acrobat Reader software application is based solely on technical considerations inherent in the PDF files this agency produces, and does not constitute an endorsement of Adobe Software as a company or of its commercially-available products. There are a multitude of free and commercial software applications offered by various software makers that are capable of opening and displaying our PDF documents, but only the Adobe Acrobat Reader application makes full and accurate use of the capabilities we have built into our documents; the agency has found over a period of many years that the Adobe Acrobat Reader provides the best, most trouble-free experience using this Commission's PDF files.