Forms

How to complete and submit forms to WorkConnections

Authorization to Release Patient Information Form

Authorization to Release Patient Information

WorkConnections staff work with the treating physicians to assist in facilitating medical care for employees. This form authorizes WorkConnections to obtain medical documentation and discuss an employee's medical condition and treatment with physicians.

Fill Out the Authorization to Release Patient Information Form

Form Instructions

  1. Employees should complete this form in its entirety via the button above.
  2. Print the form.
  3. Sign and date the form.
  4. Return the signed form to WorkConnections via email, fax, or U.S. mail.
Illness or Injury Report Form

Illness or Injury Report Form

This form should be completed by the supervisor for ALL work-related injuries or occupational illnesses. For all non-work-related disabilities, the form may be completed by the supervisor or employee.

Complete the Illness or Injury Report Form

Form Instructions
The Illness or Injury Report form can be completed and submitted entirely online.

Mileage Reimbursement Form

Mileage Reimbursement Form

University employees requesting reimbursement for mileage associated with medical treatment for work-related injuries or illnesses should complete this form.

Complete the Mileage Reimbursement Form

Form Instructions
The Mileage Reimbursement form can be completed and submitted entirely online.

Download WorkConnections forms

These forms are viewable in Adobe Acrobat Reader. Click here to download the reader from the Adobe Web site.