Medical Forms

  Authorization for Release of Medical Records

_{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.

  Employee Medical & Work Status Form

_{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.]

  Form 42

_{PDF File:  1 page; Last revised November 3, 2023}
 

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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