Get Form 42 Ct

Filling out the Form 42 is an important process for submitting a physician's permanent impairment evaluation in Connecticut's workers' compensation system. This guide will provide you with step-by-step instructions to complete the form online with clarity and ease.

Follow the steps to complete the Form 42 successfully.

1. Press the ‘Get Form’ button to access the form and open it in the editor.
2. Begin by entering the WCC file number and insurer number in the designated fields.
3. Fill in the date filed in the district, ensuring it is accurate.
4. In the employee section, provide the individual's name, date of birth, address, city or town, state, and zip code.
5. For the employer section, repeat the same process by entering the employer's name, the city or town of injury, state, and zip code.
6. Specify the details of the injury, including the date of injury and the city or town where it occurred.
7. For each body part being evaluated, use a separate Form 42. State the body part and percentage of permanent loss or loss of use.
8. Indicate whether the patient has a work capacity by checking 'Yes' or 'No.' If 'Yes,' provide any physical restrictions.
9. Specify the standards utilized in the evaluation by entering the AMA edition number or other source information.
10. The Connecticut-licensed physician must sign and print their name, include their contact number, address, city or town, state, zip code, and date.
11. Once all fields are filled accurately, save your changes, then download, print, or share the completed Form 42 as needed.

Complete all necessary documents online for a streamlined process.