Fill and Sign the Physicians Report Connecticut Form

WCC File #                                                                        MASTER OR MINOR             RIGHT EYE COMPLETE & PERMANENT LOSS OF OR REDUCTION OF AND PERMANENT LOSS OF FUNCTION OF       2.             MAXIMUM MEDICAL IMPROVEMENT IS LIKELY TO HAVE OCCURRED       EVALUATION BASED ON REVIEW OF MEDICAL RECORDS PROVIDED:             CLINICAL EVALUATION PERFORMED ON:       WHAT STANDARDS WERE UTILIZED IN YOUR EVALUATION?       IN YOUR MEDICAL OPINION, DO YOU FEEL THE PATIENT HAS A WORK CAPACITY ?       SHOULD THE PATIENT BE REFERRED FOR A PHYSICAL CAPACITIES EVALUATION ?       REPORT DATE:             42 STATE OF CONNECTICUTWORKERS' COMPENSATION COMMISSION PHYSICIAN'S REPORT OF MEDICAL EVALUATION PERMANENT MEDICAL IMPAIRMENT This section to be completed by party requesting impairment rating: INJURED WORKER INFORMATION EMPLOYER/INSURER INFORMATION PATIENT/INJURED WORKER: EMPLOYER: SOC. SEC. #- NAME (INSURER/PARTY REQUESTING EVAL.): DATE OF INJURY: ADDRESS: BODY PART(S) OR ORGAN(S) BEING EVALUATED: CONTACT PERSON & TEL. #- 1 . BILL TO: 2. 3. IF LIMB OR PART OF A LIMB, INDICATE LEFT OR RIGHT - IF HAND, ARM, OR THUMB, INDICATE CC REPORT TO: EYE INJURIES: PLEASE INDICATE WHICH EYE WAS INJURED, AND WHETHER THERE IS A COMPLETE AND PERMANENT LOSS OF SIGHT OR REDUCTION OF SIGHT TO ONE-TENTH OR LESS OF NORMAL VISION. (uncorrected vision) LEFT EYE THE ABOVE PATIENT HAS BEEN PERSONALLY ASSESSED BY ME AND IS FOUND TO HAVE A COMPLETE % % 3. % (Date) (I.E., AMA GUIDELINES, EDITION #, OR OTHER) MY OPINION IS BASED ON THE ABOVE AND IS GIVEN WITHIN REASONABLE MEDICAL PROBABILITY. (EVALUATOR/PRACTITIONER) (SIGNATURE) Rev. 1/27/2000