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Utah Form 223: Medical Treatment Authorization Request

A Utah treating physician uses this two-level form to ask the workers' compensation payor to authorize payment for proposed care, including surgery, hospitalization or any diagnostic study beyond plain X-rays. The payor must answer within five business days, and a denial must include the criteria used. If the request is denied or unanswered, the physician can ask for review by the carrier's physician on the same form.

Who completes it

The requesting provider completes the patient, carrier and Provider's Initial Request (Level One) sections and, when needed, the Level Two request for carrier physician review. The carrier records its responses, and the patient signs an acknowledgment of possible liability if the procedure is denied.

Submitting and payment

How to submit it
Send the form with supporting documentation to the payor by a verifiable transmission and record that date. For Level Two, include the days and times you are available to discuss the case with the reviewing physician.
Who pays
Under rule R612-300-11, a provider who goes ahead with non-emergency treatment without payor authorization has the fee reduced by 25% if the care proves necessary, and the payor owes nothing if it proves unnecessary.

Good to know

  • If the payor's physician does not answer a Level Two request within five business days by a method that certifies transmission, the rule treats that as authorization for payment.
  • A Level Two denial must list the criteria used, the reviewing physician's name and specialty, and appeals information, and goes to the physician, the injured worker and the Labor Commission.
  • The 25% fee reduction does not apply when another, non-workers' compensation insurer or payor already preauthorized the treatment.
  • Restorative therapy visits are requested on the RSA forms (221a, 221b, 221c), but a denial of those services can still go to Level Two review on Form 223.

Get the official form

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

Authorization Request for Medical Treatment / Carrier Response

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

How long does a Utah carrier have to answer Form 223?

Five business days at each level. At Level One the payor must send back approval or denial, with its criteria if denied, within five business days of receiving the request and documentation. At Level Two the payor's physician must finish the review within five business days, unless the payor notifies the Commission that five more days are needed.

Does the patient sign Form 223?

Yes. The patient signs an acknowledgment that they may become liable for the cost of the procedure if it is ultimately found not compensable. The form also tells the injured worker to call the Labor Commission's Division of Industrial Accidents if a disagreement with the carrier cannot be resolved.

What can be requested on Form 223?

A course of proposed treatment, including surgery, hospitalization or any diagnostic study beyond plain X-rays, with all documentation the payor needs attached. Restorative therapy visits are requested on the RSA form for the body region instead, with Form 223 available for physician review if those visits are denied.