Workers' comp, driver license medical, parking, sports, WIC, POLST and medical cannabis forms from Utah agencies, with who completes each one.
Utah clinicians meet forms from the Labor Commission, the Driver License Division (DLD), the Tax Commission's Division of Motor Vehicles, the UHSAA and the DHHS Center for Medical Cannabis. The common ones are Form 123, the Physician's Initial Report of Work Injury or Occupational Disease, the DLD 134 Functional Ability Evaluation and DLD 49 Certificate of Visual Examination, the TC-842 disability parking certification and the UHSAA Physical Form A. This hub lists 26 forms, 6 of them from the Labor Commission.
The DLD 134 rates each medical category on Utah's functional ability levels and can go through the DLD Medical Portal; DLD rejects medical and vision forms older than 6 months. Form 123 is due within 7 days of the first visit, on paper or online. UHSAA physicals must be done by a provider board certified in their discipline. 2 forms here have a Spanish version. Upload any fillable PDF to Vero Documents and it becomes a template the whole clinic can use.
Physician's first report of a work injury or occupational disease: history, ICD-coded diagnosis, work-relatedness and interpreter need, required for claims with lost time or medical treatment.
Documents functional job goals, measured capabilities (visits 1, 8, 14, 20), disability index and pain scores, and the treatment plan to request payer authorization of further restorative (PT/OT/chiropractic) visits for a spine injury injury.
Documents functional job goals, measured capabilities (visits 1, 8, 14, 20), disability index and pain scores, and the treatment plan to request payer authorization of further restorative (PT/OT/chiropractic) visits for a upper extremity injury.
Documents functional job goals, measured capabilities (visits 1, 8, 14, 20), disability index and pain scores, and the treatment plan to request payer authorization of further restorative (PT/OT/chiropractic) visits for a lower extremity injury.
Provider's request for carrier preauthorization of a medical procedure (Level One) and request for carrier physician review (Level Two), with carrier responses, under rule R612-300-11.
Form 043Last Utah treating physician's statement of condition, expected stabilization/return to work, further treatment and likely impairment when an injured worker leaves the state or changes doctors.
Vision health care professional reports acuity and visual fields (90/60 degree thresholds), stability and recommended review time or restrictions.
Health care professional rates the driver in each medical category (diabetes, cardiovascular, pulmonary, neurologic, seizures, learning/memory, mental health, alcohol/drugs, musculoskeletal, sleep, etc.) on Utah's A-K / 1-8 functional ability levels and recommends review time and restrictions.
Health care professional certifies a listed invisible condition (autism, epilepsy, diabetes, dementia, deafness, etc.) so DLD adds an identification symbol to the license/ID record shared with law enforcement (UCA 53-3-207).
Health care professional documents diagnoses, treatment and test results showing a driver cannot provide a deep-lung breath sample, supporting a petition to remove an ignition interlock requirement.
Clinician certifies a temporary (up to 6 months, not renewable) or permanent disability for Utah disability parking placards or plates.
Licensed healthcare professional's verification of an ADA disability so the applicant qualifies for a UTA Reduced Fare FAREPAY card when no other proof (e.g. Medicare) is available.
Forma Fisica (Requerido Anualmente)
Annual health history, physical examination and clearance that must be on file with the Disclosure and Consent Document before UHSAA participation.
Qualified health care professional's clearance for a student removed for a suspected concussion to return to sport (Utah Code 26B-4-4, 2011 law).
Physician release for a wrestler with a skin lesion, and physician clearance for a wrestler below the minimum body-fat percentage.
Medical exemption from Utah school and early childhood immunization requirements: parent's vaccination exemption form plus a provider notice that vaccination would endanger the student's life or health.
Medical documentation required by 7 CFR 246.10(d) for WIC to issue exempt infant formula, WIC-eligible nutritionals or non-contract formula, and to modify WIC foods, for a participant with a qualifying medical condition.
Declaración médica para solicitar comidas especiales, adaptaciones, sustitutos de leche
Medical statement supporting a meal modification (disability-related diet, allergy, texture or substitution) in the USDA school meal programs (NSLP/SBP), as required by 7 CFR 210.10(m) and Section 504/ADA.
Medical documentation required by 7 CFR 246.10(d) for WIC to issue exempt infant formula, WIC-eligible nutritionals or non-contract formula, and to modify WIC foods, for a participant with a qualifying medical condition.
Utah's statutory Life with Dignity Order recording CPR and treatment-intensity orders, honored by EMS and facilities (Utah Admin. Code R432-31).
Recommending medical provider certifies the patient's qualifying condition, card length and dosing guidelines in the patient's EVS card application.
Paper certification by a recommending medical provider sent to a medical cannabis pharmacy, which enters it into EVS; sets qualifying condition, card length, dosage-form restrictions and monthly limit.
Provider petitions the Compassionate Use Board to approve a medical cannabis card for a patient under 21 or a patient without a qualifying condition.
Report of suspected child abuse or neglect to DCFS.
Report of suspected abuse, neglect or exploitation of a vulnerable adult to Adult Protective Services.
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.
The Functional Ability Evaluation Medical Report. A health care professional rates the driver in each medical category, such as diabetes, cardiovascular, neurologic, seizures, mental health and sleep, on Utah's functional ability levels, then recommends a review time and restrictions. Up to two professionals can sign. Submit it through the DLD Medical Portal, or by email, fax or mail. DLD rejects forms older than 6 months. Vision goes on the separate DLD 49.
An MD, DO, PA-C, registered nurse practitioner or Doctor of Chiropractic, and since March 10, 2025 the provider must be board certified in their discipline. The exam goes on page 4 of Physical Form A, which is required every year and kept on file at the school with the Disclosure and Consent Document. A Spanish version (Forma Fisica) is available. Concussion clearance uses a separate UHSAA return to sport form.
As a Recommending Medical Provider: a Utah-licensed MD, DO, APRN, PA or podiatrist with 4 hours of medical cannabis CE in the last 24 months. Enter the certification in EVS after the patient starts the card application, or use the paper recommendation form, which a medical cannabis pharmacy enters into EVS. The first card visit must be in person, with some exceptions. Patients under 21 or without a qualifying condition also need a Compassionate Use Board petition.
A licensed physician, physician assistant, physical therapist or nurse practitioner. The clinician certifies either a temporary disability, for up to 6 months and not renewable, or a permanent one. The patient presents the form at a Utah DMV office for placards or plates. Paper placards carry no fee, and permanent placards do not expire.