Utah Admin. Code R612-100-3 - Forms Used By Industrial Accidents Division

A. Attending Physician's Statement - Form 043. This form must be completed by an injured worker and his Utah attending physician and then submitted to the Division with Form 044 before the injured worker changes residency from Utah to another locale as required by Subsections R612-300-2.F. and R612-300-3.C.

B. Employee's Notification of Intent to Leave Locality or State, and to Change Doctor or Hospital- Form 044. An injured worker must submit this form, together with Form 043, "Attending Physician's Statement," to the Division prior to the injured worker's change of residency from Utah to another locale as required by Subsections R612-300-2.F. and R612-300-3.C.

C. Employee Notification of Denial of Claim - Form 089. This form is used by insurance carriers or self-insured employers to notify a claimant of the reasons that the claim has been denied as required by Subsection R612-200-1.C.1.b.

D. Injured Workers' Rights and Responsibilities -- Form 100. This form is used by insurance carriers and employers to inform the injured worker of their rights and responsibilities as required by Subsection 34A-2-407(6)(b).

E. Application to Change Doctors - Form 102. This form must be submitted by an injured worker seeking to change physicians under Subsection R612-300-2.D.3.

F. Application for Self-Insurance -- Form 109. This form is submitted by an employer seeking to become self-insured under Subsection 34A-2-201.5.

G. First Report of Injury or Illness -- Forms 122C and 122E. Form 122C is used by the insurance carrier or self-insured employer to report an injury to the injured worker. Form 122E is used by the employer to report an injury to the injured worker and its insurance carrier or the Division, if uninsured. These forms are required by Subsection 34A-2-407(5).

H. Physician's Initial Report of Work Injury Or Occupational Disease - Form 123. This form is used by physicians to report initial treatment of injured employees as required by Subsection R612-300-3.A. This form must be completed by the physician for any treatment for which a bill is generated, and for any treatment beyond "first aid" as that term is defined in Subsection R612-100-2.J.

I. Final Report of Injury and Statement of Losses - Form 130. This form is used by insurance carriers or self-insured employers to report the total losses occurring in each claim. This form must be filed with the Division within 30 days from closure of each claim and shall include all payments, including medical, disability compensation, dependent's benefits, and any other payments.

J. Statement of Benefits Paid - Form 141. This form is used by insurance carriers or self-insured employers to report the initial benefits paid to a claimant as required by Subsection R612-200-1.C.1.c.

K. Statement of Suspension of Benefits - Form 142. An insurance carrier or self-insured employer must use this form to notify a claimant if disability compensation benefits are to be suspended. The form must specify the reason for suspension. The form shall be mailed to the employee and filed with the Division five days before the suspension occurs. Suspension of benefits shall not occur until 5 days after the form is mailed and filed. Exception, if reason for suspension is returned to Work or Medically Determined/Qualified to Return to Work the insurance carrier or self-insured employer has 3 days from the return/release date to complete the required reporting.

L. Authorization to Release Industrial Accident Division Records - Form 205. This form is used to request copies from an injured worker's file in the Commission with the appropriate authorized release made by the injured worker.

M. Self-Insurance Aggregate Surety Bond -- Form 213E. This form is to be completed by a self-insured employer and its surety agent to certify the surety bond has been obtained by the self-insured employer as required by Subsection R612-400-3.C.3.c.

N. Agreement of Assumption and Guaranty of Workers' Compensation -- Form 215E. This form is to be completed by a self-insured employer agreeing to assume and guarantee all liabilities and obligations as a Utah self-insurer for workers' compensation.

O. Statement of Compensation - Form 219. Insurance carriers and self-insured employers shall use this form to notify injured workers or dependents of the basis upon which compensation has been computed as required by Section R612-200-3.

P. Restorative Services Authorization/Denial - Forms 221a (Spine), 221b (Upper Extremity), and 221c (Lower Extremity). These forms must be used by any medical provider billing under the "Restorative Services" provisions of Subsections R612-300-5.C and R612-300-3.B.

Q. Authorization Request for Medical Treatment / Carrier Response -- Form 223. This form is completed by a medical provider and insurance carrier or self-insured employer when determining whether medical services were or are necessary to treat an injury under the "Utilization Review Standards" provisions of Subsection R612-300-11.

R. Renewal Application for Self-Insurance -- Form 223 E. This application is completed by a self-insured employer seeking the annual renewal required to continue to self-insure under Subsection 34A-2-201.5.

S. Request for Medical Records -- Form 302. This form is completed by an injured worker seeking a copy of medical records provided under Subsection R612-300-10.C. This form must be signed by a manager of the Division.

T. Utah Bankruptcy and Insolvency Endorsement -- Form 303. This form is to be completed by the excess insurance company for each covered self-insured entity as required by Subsection R612-400-3.C.3.b.

U. Emergency Medical Service Provider Exposure Report Form -- Form 350. This form is to be utilized by the Emergency Medical Service (EMS) Providers to document exposure to blood and/or other body fluids by an employee in EMS.

V. Notice of Further Investigation of Workers' Compensation Claim -- Form 441. This form is used by insurance carriers and self-insured employers to inform an injured worker that an additional 24 days are needed to investigate the claim.

W. Corporation and Officers Workers' Compensation Exclusion -- Form 450. This form is to be used by corporate directors and/or officers to exclude themselves from workers' compensation requirements, as allowed by Subsection 34A-2-104(4), when the corporation has no other employees.

Notes

Utah Admin. Code R612-100-3

Amended by Utah State Bulletin Number 2014-22, effective 10/22/2014 Amended by Utah State Bulletin Number 2021-02, effective 1/1/2021