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Utah Form 221c: Lower Extremity Restorative Services

Utah workers' compensation payors use this lower extremity request to decide whether to authorize more restorative visits, such as physical therapy, occupational therapy or chiropractic care. The treating provider records measurable job goals and the patient's capabilities at visits 1, 8, 14 and 20, with walk tests, LEFS or Knee Outcome Survey scores, pain ratings and hours worked. The payor then approves or denies the next block of visits on the same form.

Who completes it

The treating MD, DO, DC, PT or OT completes everything except the payor block: patient, employer and carrier details, essential job functions, capability measurements, treatment plan, expected visits and attendance. The adjuster or payor signs the approval section for visits 9-14, 15-20 or 21-26.

Submitting and payment

How to submit it
Send the completed form with supporting documentation to the adjuster or payor listed on it. Utah's utilization review rule (R612-300) requires restorative services requests to use the appropriate RSA form, and the payor returns its decision on the same document.
Who pays
The form lists no fee for completing it; it decides whether the payor will authorize payment for the next block of restorative visits, based on progress in functional goals, hours worked and pain ratings.

Good to know

  • Essential job functions must be written in objective, measurable terms, such as pounds lifted floor to shoulder or minutes on feet, because they become the goals progress is judged against.
  • The glossary defines each test: the 50-foot speed walk (8 seconds is considered a normal pace), the 6-minute walk on a hard flat surface, and single-leg stance and tandem walk balance checks.
  • Attendance is reported as visits attended against visits that should have been scheduled under the plan of care, for example 4 attended out of 9 intended.
  • If the payor denies more visits, the provider can ask for review by the carrier's physician on the Level Two section of Form 223, which also covers denied restorative services.

Get the official form

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

Restorative Services Authorization/Denial - Lower 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

When is Utah Form 221c completed?

The capability grid has columns for the first, 8th, 14th and 20th visits. Each submission updates the measurements, hours worked and pain scores and notes changes to the treatment plan, so the payor can approve or deny the next block of visits: 9-14, 15-20 or 21-26.

Which outcome measures does Form 221c use?

Besides lift, carry and push/pull maximums and functional reach, it records stairs, a 50-foot speed walk, a 6-minute walk test, the Lower Extremity Functional Scale and the Knee Outcome Survey. Patients rate average pain intensity from 0 to 10 and the percentage of the day their pain is present.

Who can complete Form 221c?

The form has checkboxes for the provider's discipline: MD, DO, DC, PT or OT. The treating provider fills in everything except the payor approval block, lists the referring physician and a tax ID number, and signs and dates the form before it goes to the adjuster.