INSTRUCTIONS: CONNECTICUT PSYCHIATRIC/SUBSTANCE ABUSE MEDICAL REPORT (Form P-142P/S)

When the Connecticut Department of Motor Vehicles receives a report that a driver may be unable to safely operate a vehicle due to abuse of medication, they will be required to receive an evaluation from a physician. The results of this evaluation will be documented and submitted on a form P-142P/S, which can be found on the website of the government of the state of Connecticut.

Connecticut Psychiatric/Substance Abuse Medical Report P-142P/S Step 1: Enter the date of the incident being addressed where indicated.

Connecticut Psychiatric/Substance Abuse Medical Report P-142P/S Step 2: The patient should enter their signature and the date in the first two blank boxes, then turn the form over to the medical professional conducting the evaluation, who will complete the rest of the form.

Connecticut Psychiatric/Substance Abuse Medical Report P-142P/S Step 3: Enter the patient's name in the first blank box, their date of birth in the second blank box, and their telephone number in the third blank box.

Connecticut Psychiatric/Substance Abuse Medical Report P-142P/S Step 4: Enter the patient's address in the fourth blank box.

Connecticut Psychiatric/Substance Abuse Medical Report P-142P/S Step 5: Enter the date of the last patient examination in the fifth blank box.

Connecticut Psychiatric/Substance Abuse Medical Report P-142P/S Step 6: In the next section, indicate the type of medication the patient is taking by placing a check mark next to the applicable medications.

Connecticut Psychiatric/Substance Abuse Medical Report P-142P/S Step 7: In the next section, document up to three medications being taken that are relevant to motor vehicle operation. Enter the name of the medication in the column on the left and the dose taken in the column on the right.

Connecticut Psychiatric/Substance Abuse Medical Report P-142P/S Step 8: Indicate with a check mark whether the patient currently suffers from convulsive seizures. If yes, give the date of their last seizure.

Connecticut Psychiatric/Substance Abuse Medical Report P-142P/S Step 9: Indicate with a check mark whether you believe the patient understands the risk posed by their condition that can affect their operation of a motor vehicle.

Connecticut Psychiatric/Substance Abuse Medical Report P-142P/S Step 10: Complete the rest of the form as instructed.

INSTRUCTIONS: CONNECTICUT INFERTILITY TREATMENT AND PROCEDURES DISCLOSURE FORM

Connecticut individuals seeking health insurance coverage for infertility treatment and procedures are required to file a form disclosing any previous such treaments for which they received coverage under a different insurance policy. This form can be found on the website maintained by the government of Connecticut.

Connecticut Infertility Treatment And Procedures Disclosure Form Step 1: Enter the name of the individual seeking treatment on the first blank line, their date of birth on the second blank line, and their Social Security number on the third blank line.

Connecticut Infertility Treatment And Procedures Disclosure Form Step 2: Indicate whether you are covered as insured or as a dependent with a check mark.

Connecticut Infertility Treatment And Procedures Disclosure Form Step 3: Enter the name of the insured on the fourth blank line.

Connecticut Infertility Treatment And Procedures Disclosure Form Step 4: Enter the current insurance carrier on the fifth blank line and your policy or ID number on the sixth blank line.

Connecticut Infertility Treatment And Procedures Disclosure Form Step 5: Indicate whether this is an individual or group plan with a check mark.

Connecticut Infertility Treatment And Procedures Disclosure Form Step 6: If applicable, etner the group name on the seventh blank line.

Connecticut Infertility Treatment And Procedures Disclosure Form Step 7: Enter the date on which you began to be insured by the policy.

Connecticut Infertility Treatment And Procedures Disclosure Form Step 8: If you have a secondary carrier, enter all information requested about them at the bottom of the first page.

Connecticut Infertility Treatment And Procedures Disclosure Form Step 9: The first section of the second page concerns your previous carrier. Enter their name on the first blank line and the policy or identification number on the second blank line.

Connecticut Infertility Treatment And Procedures Disclosure Form Step 10: Provide the name of the insured, the group number (if applicable) and the beginning and ending dates of coverage. Indicate with a check mark whether the insured was covered as insured or as a dependent, whether this was an individual or group plan, and if this was a fully insured or self insured plan.

Connecticut Infertility Treatment And Procedures Disclosure Form Step 11: Document previous treatment as instructed on the third page, then sign and date the bottom of the second page as instructed.