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.]
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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