Physicians Report Of Medical Evaluation Permanent Medical Impairment
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Physicians Report Of Medical Evaluation Permanent Medical Impairment Form. This is a Connecticut form and can be use in Workers Compensation.
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Tags: Physicians Report Of Medical Evaluation Permanent Medical Impairment, 42, Connecticut Workers Compensation,
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Rev. 4-30-2009
State of Connecticut
Workers Compensation Commission
WCC File #
42
Insurer #
Physicians Permanent Impairment
Evaluation
Date filed in District
The Form 42 should be mailed to ALL parties (employee, insurer, attorneys).
(for WCC use only)
EMPLOYEE
EMPLOYER
Name
Name
D.O.B.
INJURY
Address
Date of Injury
City/Town
State
Zip Code
City/Town of Injury
State
Tel.#
Zip Code
EVALUATION
IMPORTANT Use a separate Form 42 for EACH body part!
Connecticut Statutes do NOT recognize whole person ratings [Section 31-308(b)].
Body Part
Percentage of Permanent Loss (or Loss of Use)
LIMB is ..........................................
q
LEFT .................
q
RIGHT
Maximum Medical Improvement Exam Date
HAND, ARM, or THUMB is ...........
q
MASTER ...........
q
MINOR
Which standards were utilized in your evaluation? (AMA Edition # or Other Source)
EYE is ...........................................
q
LEFT * ..............
q
RIGHT *
* Indicate:
q
complete and permanent loss of sight
q
reduction of sight to one-tenth (1/10) or less of normal vision
CONNECTICUT-LICENSED PHYSICIAN SIGNATURE
Name
Tel. #
Address
City/Town
Signature of Connecticut-Licensed Physician
State
Zip Code
Date
Print Name of Connecticut-Licensed Physician
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