The 40 Connecticut forms that ask for a clinician's input, from school health assessments and medication orders to CT Paid Leave, DMV, HUSKY and MOLST.
This page lists the 40 Connecticut forms that ask for a clinician's input, grouped by program. School and child care forms come up most: the HAR-3 Health Assessment Record for school entry, the ED 191 for children from birth to 5, and the medication authorization that school nurses, child care staff and camps need before giving a drug. CT Paid Leave uses the Certification for Serious Health Condition. DMV issues the B-225P renewable placard, and HUSKY pharmacy requests use the Drug/Product Prior Authorization Request Form.
The B-225P and B-225T placard applications don't accept stamped signatures, and DMV takes only the original, not a fax or photocopy. Providers may not charge for the CT Paid Leave serious health condition and family care certifications, and should return them within 15 days; a completed WH-380-E or WH-380-F is accepted instead. Only MOLST-certified providers may sign the MOLST. School medical exemptions must be entered in the DPH portal. 5 forms here have a Spanish version, including the CT Paid Leave certifications.
Attending provider's report of the employee's medical status and work capacity (full, restricted or no work) for the employer and insurer.
Connecticut-licensed physician's rating of the percentage of permanent loss or loss of use of a body part at maximum medical improvement, used to set specific (permanency) benefits.
Certifies the employee's own serious health condition (inpatient care, continuing treatment, pregnancy, chronic or long-term condition) with incapacity dates for CT Paid Leave income replacement.
Certifies a family member's serious health condition and the employee's need to provide care, with dates, for CT Paid Leave caregiver benefits.
Certifies a current service member's serious injury or illness so a family member can take CT Paid Leave military caregiver leave.
P-142MMedical examiner's report on a patient referred to DMV about their ability to safely operate a motor vehicle, reviewed by DMV and its Medical Advisory Board.
Eye care professional's report on vision of a patient referred to DMV about their ability to drive safely.
Lets a hospital emergency room physician report a person diagnosed with a health problem that will significantly affect their ability to drive safely (CGS 14-46).
P-142SPEOrthopedic evaluation supporting an intrastate commercial driver's Skill Performance Evaluation (limb impairment) waiver.
P-142SWMedical report supporting an intrastate commercial driver's application for a seizure medical waiver, reviewed by the DMV Medical Advisory Board.
Applies for a renewable (permanent) disability parking placard with medical certification of blindness or a qualifying disability.
Applies for a temporary disability parking placard with medical certification of the temporary disability.
General pharmacy prior authorization request for HUSKY drugs/products (non-preferred PDL drugs, brand medically necessary, early refills, quantity changes).
UMPR-FM115253-1023HUSKY Health prior authorization request for outpatient medical/surgical services, DME (incl. customized wheelchairs), chiropractic, therapies and other outpatient services.
Therapist-authored letter of medical necessity documenting the seating/mobility evaluation for wheelchair and wheeled mobility device requests.
Prescriber order and parent authorization required before school nurses, child care staff or youth camp staff give a medication (Conn. Agencies Regs. 10-212a).
Health assessment required for children enrolling in licensed child care centers, group child care homes and preschool programs (ages birth to 5).
Registro de la Evaluación de Salud
Documents the health assessment (physical, oral health screening, immunizations) required before public school entry and again in grade 6 or 7 and grade 9 or 10 (C.G.S. 10-204a, 10-206).
Certifies that a student's remaining required school immunizations are in process per the DPH catch-up schedule so the student may attend.
Documents a medical contraindication/precaution exempting a child from required immunizations for child care, K-12 or higher education (the only exemption allowed since Public Act 21-6).
Lets a provider declare an alternative catch-up schedule for a preschool child whose religious exemption predates April 28, 2021.
Declaración médica para la modificación de alimentos en los programas de nutrición escolar
Medical statement supporting a meal modification (disability-related diet, allergy, texture or substitution) in the USDA school meal programs (NSLP/SBP), as required by 7 CFR 210.10(m) and Section 504/ADA.
Referral to WIC with the provider's anthropometric and lab data (height/length, weight, hemoglobin) and nutrition-risk information, used to certify the patient for WIC.
Medical documentation required by 7 CFR 246.10(d) for WIC to issue exempt infant formula, WIC-eligible nutritionals or non-contract formula, and to modify WIC foods, for a participant with a qualifying medical condition.
WIC 400-11Medical documentation required by 7 CFR 246.10(d) for WIC to issue exempt infant formula, WIC-eligible nutritionals or non-contract formula, and to modify WIC foods, for a participant with a qualifying medical condition.
Medical order set guiding life-sustaining treatment for patients with serious illness, signed by a MOLST-certified provider and honored across settings.
Physician's evaluation of a respondent's condition and capacity in an involuntary conservatorship (or review of an existing conservatorship) of the person or estate.
Psychologist's evaluation supporting conservatorship proceedings for a person with an intellectual disability.
Certifying prescriber initiates the patient's registration by certifying a debilitating medical condition for the palliative use of marijuana.
Certifying physician decertifies a patient, prompting DCP to notify the patient that the certification is no longer in effect (30 days to obtain a new one).
Written follow-up by a mandated reporter of an oral Careline report of suspected child abuse or neglect.
General case report of a Connecticut reportable disease, emergency illness or health condition (Category 1 and 2) unless a disease-specific form is required.
Reports chancroid, chlamydia, gonorrhea, neonatal herpes or syphilis, with treatment and partner information (CGS 19a-215).
Reports a new HIV diagnosis or AIDS in a patient 13 years or older, with risk, testing history and laboratory data.
Initial report of TB disease (confirmed or suspected) and latent TB infection, with treatment and provider information.
Written referral of suspected abuse, neglect, exploitation or abandonment of an elderly person (60+) to Protective Services for the Elderly (CGS 17b-451).
Physician, APRN or PA certifies serious illness (winter shut-off protection Nov 1-May 1), life-threatening condition (year-round protection) or infant protection under Conn. Agencies Regs. 16-3-100.
Licensed health care provider states that a summoned juror cannot, because of physical or mental disability, perform six hours a day of sedentary attentive work for three days, supporting a one-year or permanent disqualification (C.G.S. 51-217).
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
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A physician, APRN or PA completes Part 2, the medical evaluation, and the immunization record. The oral health assessment in Part 3 can be done by a dentist, dental hygienist or other provider, and the parent completes Part 1. Connecticut requires this health assessment before public school entry and again in grade 6 or 7 and grade 9 or 10 (C.G.S. 10-204a, 10-206). The parent gives the completed form to the school nurse.
Yes. CT Paid Leave accepts fully completed FMLA medical documentation such as the WH-380-E instead of its own Certification for Serious Health Condition, and the WH-380-F instead of the family member certification. Return the certification within 15 days. Providers may not charge for completing it. For pregnancy or childbirth, give actual dates, since 'TBD' leads to denial. The employee uploads it to the Aflac CT Paid Leave portal.
A physician, APRN or PA can complete Part B. For blindness, an optometrist, ophthalmologist or BESB can certify, and a VA psychiatrist can certify a veteran with PTSD. Stamped signatures are not allowed. The applicant returns the original by mail, online or in person at a DMV office; DMV doesn't take faxes, emails or photocopies. Temporary disabilities use the B-225T instead.
A physician, PA or APRN completes the Student Medical Exemption Certificate, listing ACIP contraindications or precautions by vaccine as temporary or permanent, with a signed Statement of Clinical Opinion and the immunization record attached. You must enter the exemption in the DPH Medical Exemptions Submissions Portal and give a copy to the school. Since Public Act 21-6, medical exemptions are the only kind allowed.