Authorization to Release Patient Information

Work Connections services are designed to provide you with assistance in managing your disability and safe return to work. While completion of this form is optional, by authorizing Work Connections to obtain your medical information, you enable us to meet certain university requirements in order to expedite payment of sick time or other benefits. In addition, developing a relationship with your treatment team and obtaining complete medical information is critical to coordinating an effective plan to help you.

You are responsible for providing sufficient medical documentation to support absence due to disability. Work Connections provides assistance by identifying what medical documentation is needed. As a courtesy, with authorization from the employee, Work Connections will request it from providers on your employee’s behalf. If a treatment provider is non-cooperative, Work Connections will notify you and your employer that our efforts to obtain medical documentation on the employee’s behalf have been unsuccessful.

Instructions:

  1. Complete this form in its entirety.
  2. Specifically name each doctor, hospital, or medical facility that provides you with medical care.
  3. If you choose to restrict access to specific medical information, check only those areas that apply. DO NOT check any boxes if you choose not to restrict authorization.
  4. Understand that restricting Work Connections’ ability to obtain necessary medical documentation may limit our ability to assist you.
  5. Print the form.
  6. Sign and date the form.
  7. Return the signed form to Work Connections via email, fax, or U.S. Mail.
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Mileage Reimbursement Form

Employees requesting reimbursement for mileage associated with medical treatment necessary for a work-related injury or illness may use this form.

The Mileage Reimbursement Form can be completed and submitted entirely online. If you prefer, print the form and send it to Work Connections via email, fax, or U.S. Mail.

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Healthcare Provider Statement

The Health Care Provider Statement provides a simple and easy way for physicians to provide medical information necessary to help us assist employees and departments with managing their disability.

This form normally provides enough information for case managers to evaluate an employee’s medical situation to determine what assistance may be needed, estimate the necessity of time away from work or identify required return-to-work restrictions.

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Functional Abilities Form

Work Connections case managers work with employees, supervisors, and physicians to identify opportunities for return to work as soon as it is reasonably safe for an employee to do so. The Functional Abilities Form allows physicians to indicate any restrictions that may be required to ensure a successful and safe return to work.

This form normally provides all the information necessary for case managers to evaluate an employee’s medical situation and determine what assistance or accommodations may be needed.

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