• Faculty or Staff Member Release of Medical Information Form
• Illness or Injury Report Form***
• Health Care Provider Report Form

Forms in Word Format:

• Faculty or Staff Member Release of Medical Information Form
• Illness or Injury Report Form***
• Health Care Provider Report Form

*** Effective immediately, the Illness or Injury Report Form should be used to authorize medical treatment at MWorks Clinic.

Procedure

All Campus Departments utilizing the MWorks Clinic facility for the treatment of work related injuries will now need to first complete the Illness and Injury Report Form

Fax one copy immediately to Work~Connections, and provide MWorks with a copy, as authorization for treatment.

The name and fax number of the referring department representative (usually the department supervisor), should always be included on the bottom of the Illness or Injury Report Form, in order to facilitate the receipt of regular status reports from MWorks Clinic.

The Illness or Injury Report, completely filled out by the supervisor or department representative, may be sent with the employee as authorization for treatment at MWorks Clinic, or faxed to MWorks at 998-6562

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