Injured workers in Utah who plan to leave the area or the state, or change doctors or hospitals, file Form 044 with the Labor Commission, and this statement must go with it. The worker sends it to the last physician who treated them in Utah. That physician reports the worker's condition at the last exam and, if the worker is not released to work, the expected stabilization date, further treatment and likely impairment.
The worker completes the top section with name, mailing address, date of injury, employer and carrier. The last attending physician in Utah completes items 1 to 3 and signs.
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Attending Physician's Statement
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It must accompany Form 044, the Employee's Notification of Intent to Leave Locality or State and to Change Doctor or Hospital. The injured worker asks the last Utah physician who treated them to complete it, then files both forms with the Labor Commission's Division of Industrial Accidents.
The injured worker. The form tells the physician to complete it and send it back to the worker as soon as possible, and the worker then mails it with Form 044 to the Division of Industrial Accidents. The physician does not file it directly with the Commission.