DAR File No. 38811
This rule was published in the September 15, 2014, issue (Vol. 2014, No. 18) of the Utah State Bulletin.
Labor Commission, Industrial Accidents
Section R612-100-3
Official Forms
Notice of Proposed Rule
(Amendment)
DAR File No.: 38811
Filed: 08/22/2014 08:51:57 AM
RULE ANALYSIS
Purpose of the rule or reason for the change:
The purpose of the amendments to Section R612-100-3 is to update and clarify the workers' compensation forms and filings that are required by the Industrial Accidents Division.
Summary of the rule or change:
The proposed amendment incorporate changes necessitated by the modern electronic data interchange (EDI), which has eliminated the need for filing some paper documents. The proposed change eliminates: 1) the definition of "first aid", which has been moved to a more appropriate location in Section R612-100-2; 2) reference to Form 001, "Application For Hearing", which is a form used by the Adjudication Division rather than the Industrial Accidents Division; and 3) Form 110, "Release To Return To Work", which is no longer used in connection with the Utah Injured Worker Reemployment Act. The changes also clarify and correct the description of other Division forms to conform those descriptions to actual use and practice.
State statutory or constitutional authorization for this rule:
- Section 34A-2-101 et seq.
- Section 34A-1-104 et seq.
- Section 63G-4-102 et seq.
- Section 34A-3-101 et seq.
Anticipated cost or savings to:
the state budget:
The amendment of Section R612-100-3's list and description of Division forms will not have any substantive effect on the workers' compensation system. Consequently, the proposed amendment will not result in additional administrative or enforcement costs to the Labor Commission, nor will the changes affect the state's workers' compensation coverage expenses as an employer.
local governments:
The amendment of Section R612-100-3's list and description of Division forms will not have any substantive effect on the workers' compensation system. Consequently, the proposed amendment will not change local governments' workers' compensation coverage expenses as employers.
small businesses:
The amendment of Section R612-100-3's list and description of Division forms will not have any substantive effect on the workers' compensation system. Consequently, the proposed amendment will not change small businesses' workers' compensation coverage expenses as employers.
persons other than small businesses, businesses, or local governmental entities:
The proposed change to Section R612-100-3 is consistent with current practice and will not result in any additional expense to other persons.
Compliance costs for affected persons:
The elimination of unnecessary forms and clarification of descriptions of forms that continue in use will assist stakeholders in understanding and using the workers' compensation system. The proposed amendment is not expected to result in any additional compliance costs for affected persons.
Comments by the department head on the fiscal impact the rule may have on businesses:
The proposed changes to Section R612-100-3 are part of the Industrial Accidents Division's comprehensive review of all its workers' compensation rules. As already noted, the proposed amendment is not substantive in nature, but works to simplify, update, and clarify the Division's workers' compensation forms. As such, the amendment will not increase stakeholder costs, but should make use of the Division's rules easier.
Sherrie Hayashi, Commissioner
The full text of this rule may be inspected, during regular business hours, at the Division of Administrative Rules, or at:
Labor CommissionIndustrial Accidents
HEBER M WELLS BLDG
160 E 300 S
SALT LAKE CITY, UT 84111-2316
Direct questions regarding this rule to:
- Ron Dressler at the above address, by phone at 801-530-6841, by FAX at 801-530-6804, or by Internet E-mail at rdressler@utah.gov
Interested persons may present their views on this rule by submitting written comments to the address above no later than 5:00 p.m. on:
10/15/2014
This rule may become effective on:
10/22/2014
Authorized by:
Sherrie Hayashi, Commissioner
RULE TEXT
R612. Labor Commission, Industrial Accidents.
R612-100. Workers' Compensation Rules - General Provisions.
[R612-100-3. Official Forms.
A. "Employer's First Report of Injury - Form
122" - This form is used for reporting accidents, injuries,
or occupational diseases as per Section 34A-2-407. This form must
be filed within seven days of the occurrence of the alleged
industrial accident or the employer's first knowledge or
notification of the same. This form also serves as OSHA Form 301.
The employer must report all injuries, other than first aid
administered on site or at an employer sponsored free clinic, to
the Industrial Accident Division and to the insurance carrier.
First aid treatment is defined as:
a. non-prescription medications at non-prescription
strength;
b. administering tetanus immunizations;
c. cleaning, flushing, or soaking wounds on the skin
surface;
d. using wound coverings, such as bandages, Band Aid
(TM), gauze pads, etc., or using SteriStrips (TM) or butterfly
bandages;
e. using hot or cold therapy (limited to hot or cold
packs, contrast baths and paraffin);
f. using any totally non-rigid means of support, such as
elastic bandages, wraps, non-rigid back belts, etc.;
g. using temporary immobilization devices while
transporting an accident victim (splints, slings, neck collars,
or back boards);
h. drilling a fingernail or toenail to relieve pressure,
or draining fluids from blisters;
i. using eye patches; using simple irrigation or a cotton
swab to remove foreign bodies not embedded in or adhered to the
eye;
j. using irrigation, tweezers, cotton swab or other
simple means to remove splinters or foreign material from areas
other than the eye;
k. using finger guards;
l. using massages;
m. drinking fluids to relieve heat stress;
First aid, as defined above, is limited to a one-time
visit and one subsequent follow up visit within a 7 day time
period. (This does not apply to reporting it on OSHA's 300
log). However, if first aid treatment is given by a licensed
health professional in an employer sponsored free clinic then two
subsequent visits within a 14 consecutive day time period are
allowed. The employer must maintain the employer's injury
report (Form 122) and health records on site for first aid
treatment.
First aid, as defined in a through m, does not include
any work injuries resulting in:
i) loss of consciousness;
ii) loss of work;
iii) restriction of work; or
iv) transfer to another job.
B. "Physician's Initial Report of Work Injury or
Occupational Disease - Form 123" - This form is used by
physicians and chiropractors to report their initial treatment of
an injured employee. This form must be completed when a bill is
generated for treatment administered by a licensed health care
provider, as defined in 34A-2-11. This form is also to be
completed by the health care provider if treatment, beyond first
aid, is given at an employer sponsored free clinic. The form must
be cosigned by the supervising physician, unless the form is
completed by a nurse practitioner.
C. "Restorative Services Authorization - Forms
221(a) Spine, 221(b) Upper Extremity, and 221(c) Lower
Extremity" - These forms are to be used by any medical
provider billing under the restorative services section of the
Commission's adopted Resource-Based Relative Value Scale and
the Medical Fee Guidelines. The medical provider shall file the
appropriate form with the insurance carrier or self-insured
employer and the division within ten days of the initial
evaluation. After the initial filing, an updated Restorative
Services Authorization form must be filed for approval or denial
at least every six visits until a fixed state of recovery has
been reached.
D. "Statement of Insurance Carrier or Self-Insurer
with Respect to Payment of Benefits - Form 141" - This form
is used for reporting the initial benefits paid to an injured
employee. This form must be filed with or mailed to the division
on the same date the first payment of compensation is mailed to
the employee. A copy of this form must accompany the first
payment.
E. "Employee Notification of Denial of Claim - Form
089" - This form is used by insurance carriers or
self-insured employers to notify the claimant that his or her
claim, in whole or part, is denied and the reason(s) why the
claim is being denied. An insurance carrier or self-insured
employer shall complete its investigation within 45 days of
receipt of the claim and shall commence the payment of benefits
or notify the claimant and the division in writing that the
claim, in whole or part, is denied.
F. "Insurance Carriers/ Self-Insurer's Notice of
Further Investigation of a Workers' Compensation Claim - Form
441" - This form is used by insurance carriers or
self-insured employers to notify the claimant and the commission
that further investigation is needed and the reasons for further
investigation. This form or letter containing similar information
is to be filed within 21 days of notification of claim that
further investigation is needed.
G. "Statement of Insurance Carrier or Self-Insurer
with Respect to Suspension of Benefits - Form 142" - This
form is to be used by insurance carriers or self-insured
employers to notify an employee of the suspension of weekly
compensation benefits. The form must be mailed to the employee
and filed with the division five days before the date
compensation is suspended. The insurance carrier or self-insured
employer must specify the reason for the suspension of
benefits.
H. "Application for Hearing - Form 001" - Used
by an applicant for instituting an industrial claim against an
insurance carrier, self-insured employer, or uninsured employer.
This form, obtainable from the division, must be filed and signed
by the injured employee or his/her agent. All blanks must be
completed to the best knowledge, belief, or information of the
injured employee.
I. "Claim for Dependents' Benefits and/or Burial
Benefits - Form 025" - This form is used by the dependent(s)
of a deceased employee to seek benefits as a result of a fatal
accident or occupational disease occurring in the course of
employment.
1. This form must be filed before a hearing or an award
is made, and pleadings will not be accepted in lieu thereof. If
pleadings are submitted, the attorney so filing will be supplied
the form for filing before any proceedings are
initiated.
2. The filing of this form by the surviving spouse on
behalf of the surviving spouse and the surviving spouse's
dependent minor children is sufficient for all
dependents.
3. Unless otherwise directed by an Administrative Law
Judge, the following information shall be supplied before an
Order or an Award is made:
(a) A certified copy of the marriage license and birth
certificates of dependent minor children. If such evidence is not
readily available, the Administrative Law Judge will determine
the adequacy of substitute evidence.
(b) Adoption papers or other decrees of courts of record
establishing legal responsibility for support of dependent
children.
(c) If either the deceased employee or surviving spouse
has been involved in divorce proceedings, copies of decrees and
orders of the court should be supplied.
J. "Insurance Company's and Self-Insurer's
Final Report of Injury and Statement of Total Losses - Form
130" - This form is used by insurance carriers and
self-insurers to report the total losses occurring in a claim for
any benefits. This form must be filed with the division as soon
as final settlement is made but in no event more than 30 days
from such settlement. This form shall be filed for all losses
including medical only, compensation, survivor benefits, or any
combination of all so as to provide complete loss information for
each claim.
K. "Dependents' Benefit Order - Form 151" -
This form is used by the division in all accidental death cases
where no issue of liability for the death or establishment of
dependency is raised and only one household of dependents is
involved. The carrier indicates acceptance of liability by
completing the top half of the form and filing it with the
division.
L. "Medical Information Authorization - Form
046" - This form is used to release the applicant's
medical records to the Commission or the chairman of a medical
panel appointed by an Administrative Law Judge.
M. "Application to Change Doctors - Form 102" -
This form must be used by the employee pursuant to the provisions
of Rule R612-2-9 as contained herein.
N. "Employee's Notification of Intent to Leave
Locality or State, and to Change Doctor or Hospital - Form
044" - As per Section 34A-2-604, this form is used by the
employee and must be accompanied by the "Attending
Physician's Statement - Form 043" before Commission
approval can be granted. Otherwise, compensation may not be
allowed.
O. "Attending Physician's Statement - Form
043" - This form must be completed by employee and his last
attending physician in the state to establish the medical
condition of the employee. It must be accompanied by Form
044.
P. "Compensation Agreement - Form 219" - This
form is used by the parties to a workers' compensation claim
to enter into an agreement as to a permanent partial impairment
award, and must be submitted to the Division of Industrial
Accidents for approval.
Q. "Application for Lump Sum or Advance Payment -
Form 134" - This form is used by an employee to apply for a
lump sum or advance payment for a permanent partial impairment
award.
R. "Release to Return to Work - Form 110" -
This form may be used to meet the requirements of Rule
R612-2-3(D), as contained herein.
S. "Request for Copies From Claimant's File -
Form 205" - This form is used to request copies from a
claimant's file in the Commission with the appropriate
authorized release.
T. Reemployment Program Forms
1. "Initial Assessment Report - Form 206" -
This form is completed either by the self-insured employer, the
workers' compensation insurance provider, or by a
rehabilitation agency contracted by the employer/carrier. The
report contains claimant demographics and insurance coverage
details, and addresses the issue of need for vocational
assistance.
2. "Request for Decision of Administrative Review -
Form 207" - This form is completed when the employee wishes
to contest the information/decision made by the carrier or
rehabilitation agency.
3. "U.S.O.R. Rehabilitation Progress Report - Form
208A" - This form shall be requested from the Utah State
Office of Rehabilitation at each stage of the reemployment
process (eligibility determination, reemployment plan
development/implementation and case closure) or at any
interruption of the process. An Individualized Written
Rehabilitation Program (USOR 5 IWRP) shall also be requested when
a plan is developed. All other private rehabilitation providers
shall submit a Form 206 for any plan progress, postponement, or
interruption in the plan.
4. "Reemployment Plan - Form 209" - This form
is used for either an original or amended work plan. The form
contains the details and estimated costs in returning the injured
worker to the work force.
5. "Reemployment Plan Closure Report - Form
210" - This form is submitted to the division upon
completion of the reemployment plan. The closure report shall
detail costs by category either by dollar amounts or time
expended (only in the categories of evaluation and counseling).
The report shall also contain all the details on the return to
work.
6. "Application for Certification as a Reemployment
Provider - Form 212" - This form is completed by
rehabilitation providers who wish to be certified by the
division. It contains provider demographics, Utah staff
credentials, services/fees, and references.
7. "Administrative Review Determination - Form
213" - This form is used by the division to summarize the
outcome of the administrative review.
U. "Medical Records - Copies - Form 302" - This
form is used by a claimant to request a free copy of his/her
medical records from a medical provider. This form must be signed
by a staff member of the division.
V. The division may approve change of any of the above
forms upon public notice. Carriers may print these forms or
approved versions.]
R612-100-3. Forms Used By Industrial Accidents Division.
A. 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 R612-300-4.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 Section R612-100-2.
B. Restorative Services Authorization - 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 Subsection R612-300-5.G.
C. Statement of Benefits Paid by Insurance Carrier or Uninsured Employer - Form 141. This form is used by insurance carriers and uninsured employers to report the initial benefits paid to a claimant as required by Subsection R612-200-1.C.1.c.
D. Employee Notification of Denial of Claim - Form 089. This form is used by insurance carriers or uninsured employers, as required by Subsection R612-200-1.C.1.b. to notify a claimant of the reasons that the claim has been denied.
E. Statement of Suspension of Benefits - Form 142. An insurance carrier or uninsured 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.
F. Final Report of Injury and Statement of Losses - Form 130. This form is used by insurance carriers and uninsured 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.
G. Dependents' Benefit Order - Form 151. This form is used by the Division in all accidental death cases where no issue of liability for the death or establishment of dependency is raised and only one household of dependents is involved. The carrier indicates acceptance of liability by completing the top half of the form and filing it with the Division.
H. Medical Information Authorization - Form 046. This form is used to release the applicant's medical records for use by the Commission or its subdivisions.
I. Application to Change Doctors - Form 102. This form must be submitted by an injured worker seeking to change physicians as provided by Subsection R612-300-2.D.3.
J. Notice of Intent to Leave State - Form 044. As required by Subsection R612-300-2.F. 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.
K. Attending Physician's Statement - Form 043. As required by Subsection R612-300-2.F., 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.
L. Statement of Compensation - Form 219. As required by Section R612-200-5, insurance carriers and uninsured employers shall use this form to notify injured workers or dependents of the basis upon which compensation has been computed.
M. Request for Copies from Claimant's File - Form 205. This form is used to request copies from a claimant's file in the Commission with the appropriate authorized release.
N. Reemployment Program Forms.
1. "Initial Assessment Report - Form 206" - This form is completed either by the self-insured employer, the workers' compensation insurance provider, or by a rehabilitation agency contracted by the employer/carrier. The report contains claimant demographics and insurance coverage details, and addresses the issue of need for vocational assistance.
2. "Request for Decision of Administrative Review - Form 207" - This form is completed when the employee wishes to contest the information/decision made by the carrier or rehabilitation agency.
3. "U.S.O.R. Rehabilitation Progress Report - Form 208A" - This form shall be requested from the Utah State Office of Rehabilitation at each stage of the reemployment process (eligibility determination, reemployment plan development/implementation and case closure) or at any interruption of the process. An Individualized Written Rehabilitation Program (USOR 5 IWRP) shall also be requested when a plan is developed. All other private rehabilitation providers shall submit a Form 206 for any plan progress, postponement, or interruption in the plan.
4. "Reemployment Plan - Form 209" - This form is used for either an original or amended work plan. The form contains the details and estimated costs in returning the injured worker to the work force.
5. "Reemployment Plan Closure Report - Form 210" - This form is submitted to the Division upon completion of the reemployment plan. The closure report shall detail costs by category either by dollar amounts or time expended (only in the categories of evaluation and counseling). The report shall also contain all the details on the return to work.
6. "Application for Certification as a Reemployment Provider - Form 212" - This form is completed by rehabilitation providers who wish to be certified by the Division. It contains provider demographics, Utah staff credentials, services/fees, and references.
7. "Administrative Review Determination - Form 213" - This form is used by the Division to summarize the outcome of the administrative review.
O. Medical Records - Form 302. This form is used by a claimant to request a free copy of his or her medical records from a medical provider. This form must be signed by a staff member of the Division.
KEY: workers' compensation, administrative procedures
Date of Enactment or Last Substantive Amendment: [February 25, 2013]2014
Authorizing, and Implemented or Interpreted Law: 34A-2-101 et seq.; 34A-3-101 et seq.; 34A-1-104 et seq.; 63G-4-102 et seq.
Additional Information
More information about a Notice of Proposed Rule is available online.
The Portable Document Format (PDF) version of the Bulletin is the official version. The PDF version of this issue is available at https://rules.utah.gov/publicat/bull-pdf/2014/b20140915.pdf. The HTML edition of the Bulletin is a convenience copy. Any discrepancy between the PDF version and HTML version is resolved in favor of the PDF version.
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For questions regarding the content or application of this rule, please contact Ron Dressler at the above address, by phone at 801-530-6841, by FAX at 801-530-6804, or by Internet E-mail at rdressler@utah.gov. For questions about the rulemaking process, please contact the Division of Administrative Rules.