Utah Admin. Code R612-300-3 - Required Reports

A. Physician's Initial Report of Work Injury Or Occupational Disease - Form 123. Within one week after providing initial medical care to an injured worker, a health care provider shall complete "Form 123 - Physicians' Initial Report." The provider shall fully complete Form 123 according to its instructions. The provider shall then file Form 123 with the Division and payor.

1. Form 123 must be completed and filed for every initial visit for which a bill is generated, including first aid, when the worker reports that his or her medical condition is work related.

2. If initial medical care is provided by any health care provider other than a physician, Form 123 must be countersigned by the supervising physician.

B. Form 221, Restorative Services Authorization. Form 221, "Restorative Services Authorization Form" required by Subsection R612-300-5. C. 7. shall be filed with both the payor and the Division.

C. Forms 043, Attending Physician's Statement, and Form 044, Employee's Notification of Intent to Leave Locality or State and to Change Doctor or Hospital. These forms are to be submitted to the Division before an injured worker leaves Utah.

Notes

Utah Admin. Code R612-300-3

Amended by Utah State Bulletin Number 2014-22, effective 10/22/2014 Amended by Utah State Bulletin Number 2019-2, effective 1/1/2019 Amended by Utah State Bulletin Number 2020-02, effective 12/23/2019 Amended by Utah State Bulletin Number 2021-02, effective 1/1/2021