State of Connecticut Human Resources Medical Certificate 2025

1. Click ‘Get Form’ to open the State of Connecticut Human Resources Medical Certificate in the editor.
2. Begin by filling in the 'Agency Name' and 'Address' sections at the top of the form. Ensure that you provide accurate details for proper submission.
3. In the 'Employee’s Name and Employee’s Number' section, enter your full name and employee number. This information is crucial for identification purposes.
4. Next, complete the 'Patient’s Name' and 'Relationship to Employee' fields. Specify your relationship to the individual requiring care, whether it be a spouse, child, or parent.
5. Proceed to Section (1) where you will indicate if the patient's condition qualifies as a serious health condition. Check the appropriate boxes based on your situation.
6. In Section (3), provide details about the condition's commencement date, duration, and any necessary medical facts that support your certification.
7. Finally, ensure that all sections are completed accurately before submitting. You can easily sign and send this document directly from our platform for free.

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