Utah Labor Commission forms clinicians complete on work injury claims, from the Form 123 initial report to restorative therapy authorizations and preauthorization requests.
The Utah Labor Commission's Division of Industrial Accidents issues the medical forms used on Utah workers' compensation claims. The treating physician files Form 123, the Physician's Initial Report of Work Injury or Occupational Disease, for any claim with lost time or medical treatment. It records the history, an ICD-coded diagnosis, work-relatedness and interpreter need. Form 223 requests carrier preauthorization of a procedure, and Forms 221a, 221b and 221c request more restorative therapy visits for spine, upper extremity and lower extremity injuries.
File Form 123 within 7 days of the initial visit. The carrier gets a copy with your bill and progress notes, and the employee, employer and Labor Commission get the form alone. You can also file it online through Easy Online 123. MDs, DOs, chiropractors, physical therapists and occupational therapists complete the 221 forms, and the adjuster approves or denies visits on the same form. When a worker leaves Utah or changes doctors, the last Utah attending physician completes Form 043. All forms are in English.
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.
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.
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.
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Within 7 days of the initial visit, under Utah Admin. Code R612-100-3(H). Send a copy with your bill and progress notes to the insurance carrier, and send the form alone to the employee, the employer and the Labor Commission. The Commission also takes Form 123 online through Easy Online 123, which requires registration. The report is required for claims with lost time or medical treatment.
They are Restorative Services Authorization/Denial forms for spine (221a), upper extremity (221b) and lower extremity (221c) injuries. The treating MD, DO, DC, PT or OT records functional job goals, measured capabilities at visits 1, 8, 14 and 20, disability index and pain scores, and the treatment plan. The payor or adjuster approves or denies further visits on the same form.
Use Form 223, Authorization Request for Medical Treatment / Carrier Response, under rule R612-300-11. The provider's initial request is Level One, and a request for review by the carrier's physician is Level Two. Send it to the carrier or adjuster by verified transmission with supporting documentation. The patient signs an acknowledgment of liability in case the request is denied.
It is the Attending Physician's Statement for a worker who leaves Utah or changes doctors. The last attending physician in Utah completes items 1 to 3 on the worker's condition, expected stabilization or return to work, further treatment and likely impairment, then signs. The worker completes the header and sends it with Form 044 to the Labor Commission's Division of Industrial Accidents.