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Click ‘Get Form’ to open the Physicians Report - Connecticut in the editor.
Begin by filling out the 'Injured Worker Information' section. Enter the patient's name, Social Security number, and date of injury.
Next, complete the 'Employer/Insurer Information' section. Provide the employer's name and contact details for the party requesting the evaluation.
In the 'Body Part(s) or Organ(s) Being Evaluated' field, specify which parts of the body are affected. If applicable, indicate if it involves a limb and whether it's left or right.
For eye injuries, clearly state which eye was injured and detail any loss of sight in the respective fields provided.
Complete the clinical evaluation section by entering your assessment date and any standards utilized during your evaluation.
Finally, provide your medical opinion regarding work capacity and whether a physical capacities evaluation is necessary before signing and dating the report.
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