In observance of Thanksgiving, WCC offices will be closed on Thursday, November 24, 2022.

Medical Forms

 

link opens in new browser tab  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.

 


 

link opens in new browser tab  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  link opens in new browser tab  Payor and Medical Provider Guidelines publication, which describes the purpose and proper use of this form.]

 


 

link opens in new browser tab  Form 42

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.

 


 

The Workers' Compensation Commission recommends the use of Adobe's free Adobe Acrobat Reader software application when accessing or using its PDF forms and publications.

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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.