STEP 2
Submit Forms
Submit Form: 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:
- Complete this form in its entirety.
- Specifically name each doctor, hospital or medical facility that provides you with medical care.
- 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.
- Understand that restricting Work Connections’ ability to obtain necessary medical documentation may limit our ability to assist you.
- Print the form.
- Sign and date the form.
- Return the signed form to Work Connections via email, fax, or U.S. Mail.
Submit Form: Medical Leave Form
This form is provided for your convenience in order to obtain a quick summary of medical issues from your treating physician. The form should be completed by a treating health care provider and returned to Work Connections via email, fax, or U.S. Mail.
“The Work Connections staff helped me navigate through the paperwork related to my surgery and subsequent time off. They kept in touch via e-mail to make sure I was recuperating as expected. They served as advocates, as well as being liaisons between myself, leadership, and my care providers. I am grateful!”
Sandy Raymond
RN
Northville/Canton Infusion
“When I was in one of the most difficult times in mine and my family’s lives, it was so comforting to be able to reach out and feel as if I had my own personal cheerleader, reassuring me that everything with my job and my supervisor would be taken care of so that I could focus on my illness and healing. I don’t think I can express in words my gratitude for having the stress of any potential problems with my job lifted from me during that overwhelming period of my life.”
Celeste Weissinger
RN, BSN
University of Michigan Visiting Nurses
“Work Connections does an amazing job in recognizing just what it takes to get better: not just good medical treatment but a caring and knowledgeable staff that gives you time to heal and protects you from rushing back to work too soon. Every day after my hip replacement surgery I said to my husband: I’m so glad I’m not teaching. I would never have been able to do it and it was my Work Connections nurse who wisely told me so before the surgery.”
Deborah Dash Moore
Frederick G. L. Huetwell Professor of History and Judaic Studies
“I can’t say enough about Work Connections. They really understood my case and collaborated with me on a routine basis during my leave and after my return. Additionally, they connected me with other high quality caregivers so that I could just focus on wellness. In my 35th year as an employee I needed help and Work Connections came through in a way that can only be described as a blessing.”
Kevin Donovan
Business Planning Manager
Medical School
“I absolutely love Work Connections! This department is so very important to managers, supervisors and administrative assistants. They ensure that the correct documents are being used and verify information from medical providers. A quick referral to them can make a big difference in the workload surrounding an employee’s illness. They take care of the phone calls and follow up with the employee. I am happy Michigan Medicine has this service and highly recommend it.”
Robin Russell
RN
8 C Nursing Supervisor
