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Utah Form 221b: Restorative Services (Upper Extremity)

For upper extremity injuries in Utah workers' compensation, therapy and chiropractic providers use this form to show progress and ask the payer to authorize the next block of visits. Alongside job-based lifting goals, it tracks grip and pinch strength, a dexterity test, the DASH, a hand function sort, hours worked and pain at visits 1, 8, 14 and 20. The payer approves or denies future visits on the form.

Who completes it

The treating provider, an MD, DO, DC, PT or OT, completes everything except the payor block. The adjuster marks approval or denial for visits 9 to 14, 15 to 20 and 21 to 26 and signs.

Submitting and payment

How to submit it
Send the form to the payor or adjuster at each authorization point; the decision comes back on the same form.
Who pays
The payor's approval or denial on the form decides whether further restorative visits are authorized.

Good to know

  • Grip strength is measured with a dynamometer at the second handle position three times; a rapid exchange grip that exceeds standard grip indicates an invalid effort.
  • Pinch strength covers key, palmar and tip pinch; a two-point pinch stronger than three-point pinch indicates an invalid effort, per the glossary.
  • Dexterity tests described in the glossary include the Purdue Pegboard, Minnesota Rate of Manipulation, Bennett Hand-Tool and VALPAR.
  • Improvement in functional goals, hours worked and pain ratings is what the payer uses to decide on further treatment.

Get the official form

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

Restorative Services Authorization/Denial - Upper Extremity

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.

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Frequently asked questions

What is the difference between Utah Forms 221a and 221b?

Form 221a is for spine injuries and uses the Modified Oswestry or Neck Disability Index with sitting, standing and bending tolerances. Form 221b is for upper extremity injuries and replaces those with grip and pinch strength, a dexterity test, the DASH and a hand function sort.

How should goals be written on Form 221b?

The glossary asks for essential job functions in specific, measurable terms, such as pounds lifted, length of reach or minutes of a task, compared with the job description. Examples include light assembly above eye level for up to 20 minutes at a time, or typing for 45 minutes without increased symptoms.