Connecticut pays specific (permanency) workers' compensation benefits based on a physician's rating of permanent loss, or loss of use, of a body part once the worker reaches maximum medical improvement. Form 42 is where the Connecticut-licensed physician reports that rating: the body part and side, the standards used, the percentage, the MMI exam date, and any work capacity and restrictions.
A Connecticut-licensed physician completes and signs the evaluation, including the employee's required date of birth. There is no section for the employee or employer to complete.
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Physician's Permanent Impairment Evaluation
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No. Form 42 states that Connecticut statutes do not recognize whole person ratings, citing section 31-308(b). The physician rates the percentage of permanent loss or loss of use of a specific body part, using a separate Form 42 for each body part.
The form says it should be mailed to all parties, meaning the employee, the insurer and any attorneys. The form also has a box, reserved for Commission use, for the date it was filed in the district office.
The form does not mandate one; it asks which standards were used, listing the AMA Guides edition number or other source. The physician also gives the date of the maximum medical improvement exam and states whether the patient has a work capacity, listing any physical restrictions.