Verification Of Medical Appointment Form printable pdf download

Verification Of Medical Appointment Form

DEPARTMENT OF MENTAL HEALTH AND ADDICTION SERVICES

VERIFICATION OF MEDICAL APPOINTMENT FORM

This form must be completed by the Medical Service Provider

Employees must take this form to each workers’ compensation medical appointment

made during or after their regular working hours. The employee’s time sheet should be

coded “WSPC” for the time it takes the employee to travel to the appointment, while they

are at the appointment, and the time it takes the employee to return to work.

Employees’ will be paid only for the time at the appointment when the appointment is

after work hours, or on scheduled days off. Payment for these appointments will be paid

through the Third Party Administrator, and not through payroll.

This form must be attached to the corresponding time sheet, or faxed to the Departments

Workers’ Compensation Unit. (Fax # 860-262-5003)

Employee Name: ________________________________________________________

Medical Service Provider: _________________________________________________

Appointment Date: _________________ Appointment Start Time: ______________

Appointment End Time : _____________

Is this appointment due to a work related injury/illness? _____ yes

_____ no

_______________________________________

_________________________

Medical Service Provider Signature

Date

Address

Town,

State

Verification Of Medical Appointment Form