Try for free

Utah Form 221a: Restorative Services (Spine)

Utah workers' compensation payers use this form to decide whether a spine patient's physical therapy, occupational therapy or chiropractic care continues past each block of visits. The provider records essential job demands as measurable goals, then tracks lifting, tolerances, the Modified Oswestry or Neck Disability Index, hours worked and pain at visits 1, 8, 14 and 20. The payer approves or denies the next block on the same form.

Who completes it

The treating provider, an MD, DO, DC, PT or OT, completes everything except the payor block. The adjuster completes the payor section approving or denying visits 9 to 14, 15 to 20 and 21 to 26.

Submitting and payment

How to submit it
Send the form to the payor or adjuster at each authorization point; the payor returns its decision on the same form.
Who pays
The payor's approval or denial on the form decides whether the next block of restorative visits is authorized.

Good to know

  • The glossary says improvement in stated functional goals, hours worked and pain ratings will be used to decide whether further treatment is authorized.
  • Goals should be objective and measurable, such as occasional lifts of 30 pounds from floor to shoulder or standing up to 2 hours at a time.
  • Lifts are recorded floor to waist, waist to shoulder and overhead as maximum pounds and frequency, plus carrying and push or pull force.
  • Attended versus prescribed visits is reported as a ratio, for example 4 attended of 9 intended when the plan called for three visits a week.

Get the official form

Download the current version from the source each time; forms change without notice.

Restorative Services Authorization/Denial - Spine

Official pagePDF

How this list is checked

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.

Frequently asked questions

When is Utah Form 221a submitted?

Capabilities are recorded on the first visit and again on the 8th, 14th and 20th visits, and the payor marks approval for visits 9 to 14, 15 to 20 and 21 to 26. Each submission updates the treatment plan and shows progress toward the job-based goals.

Which outcome questionnaires does Form 221a use?

The Modified Oswestry Disability Questionnaire for the lumbar spine and the Neck Disability Index for the cervical spine, both described in the form's glossary with links to scoring. The glossary also describes the Quadruple Visual Analog Scale for pain intensity.