Utah Administrative Code

The Utah Administrative Code is the body of all effective administrative rules as compiled and organized by the Division of Administrative Rules (see Subsection 63G-3-102(5); see also Sections 63G-3-701 and 702).

NOTE: For a list of rules that have been made effective since January 1, 2020, please see the codification segue page.

NOTE TO RULEFILING AGENCIES: Use the RTF version for submitting rule changes.

R612. Labor Commission, Industrial Accidents.

Rule R612-100. Workers' Compensation Rules - General Provisions.

As in effect on January 1, 2020

Table of Contents

R612-100-1. Authority.

These rules are enacted pursuant to the following statutory authority:

A. Section 34A-1-104 of the Utah Labor Commission Act;

B. Section 34A-2-103, 34A-2-201.3, 34A-2-407 and 34A-2-412 of the Utah Workers' Compensation Act;

C. Section 34A-2-1001 et seq. of the Workers'; Compensation Coverage Waiver Act;

D. Section 59-9-101 of the Taxation of Admitted Insurers Act;

E. Section 63G-4-202(1) of the Utah Administrative Procedures Act; and

F. Section 78B-8-404 of Chapter 8, Title 78B, Utah Code Annotated.

R612-100-2. Definitions.

A. "Administrative Law Judge" or "ALJ" means a person designated by the Commission to hear and decide disputed cases.

B. "Claimant" means an injured employee, dependent(s)of an injured employee, medical providers, or any other person seeking relief or claiming benefits under the Utah Workers' Compensation Act or Utah Occupational Disease Act.

C. "Award" means a determination of the Commission, Appeals Board or Administrative Law Judge of the benefits due a claimant.

D. "Benefits" includes any payment, entitlement, or other relief provided under the Utah Workers' Compensation Act or Utah Occupational Disease Act.

E. "Commission" means the Utah Labor Commission.

F. "Defendant" means an employer, insurance carrier, Employers' Reinsurance Fund, Uninsured Employers' Fund or other person or entity against whom a claim for benefits is made.

G. "Division" means the Division of Industrial Accidents within the Commission.

H. "Disabled Injured Worker" means an injured worker who:

1. because of the injury or disease that is the basis for the employee being an injured worker:

a. is or will be unable to return to work in the injured worker's usual and customary occupation; or

b. is unable to perform work for which the injured worker has previous training and experience; and

2. reasonably can be expected to attain gainful employment after an evaluation provided for in accordance with Section 34A-2-413.5.

I. "Employer" is defined in Section 34A-2-103 of the Utah Workers Compensation Act and includes self-insured employers and uninsured employers.

J. "First Aid" is medical care that is:

1. administered on-site or at an employer-sponsored free clinic; and

2. limited to the following:

a. non-prescription medications at non-prescription strength:

b. tetanus immunizations;

c. cleaning and applying bandages to skin surface wounds;

d. hot or cold packs, contrast baths and paraffin;

e. non-rigid support, such as elastic bandages, wraps, and back belts;

f. temporary immobilization devices for transporting an accident victim, such as splints, slings, neck collars, or back boards;

g. drilling a fingernail or toenail to relieve pressure, or draining fluids from blisters;

h. eye patches or use of simple irrigation or a cotton swab to remove foreign bodies not embedded in or adhering to an eye;

i. use of irrigation, tweezers, or cotton swab to remove splinters or foreign material;

j. finger guards;

k. massages;

l. drinking fluids to relieve heat stress.

3. "First aid" is limited to initial treatment and one follow-up visit within a seven-day period after the initial treatment, except that if first aid treatment was provided by a licensed health professional in an employer-sponsored free clinic, first aid includes initial treatment and two follow-up visits within a fourteen-day period after the initial treatment.

4. "First aid" does not include any treatment of a work injury that results in:

a. loss of consciousness;

b. loss of work;

c. restriction of work;

d. transfer to another job.

K. "Injury" includes work-related accidental injury and occupational disease.

L. "Insurance Carrier" includes any worker's compensation insurance carriers, self-insured employer and self-insured employer's adjusting company, unless otherwise specified.

M. "Payor" means any insurance carrier, self-insured employer, or uninsured employer that is liable for any benefit or other relief under the Utah Workers' Compensation Act or Utah Occupational Disease Act.

N. "Usual and Customary Rate (UCR)" is the rate of payment using Ingenix, or a similar service, for charges for services in a particular zip code.

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.

R612-100-4. Designation as Informal Proceedings.

A. Pursuant to Section 63G-4-202, the following are designated as informal adjudicatory proceedings:

1. Assessment of penalty under Section 34A-2-211 against an employer conducting business without obtaining workers' compensation coverage;

2. Assessment of penalty under Section 34A-2-201.3 against an insured employer for direct payment of workers' compensation benefits;

3. Assessment of penalty under Section 34A-2-407 against an employer or insurance carrier who does not timely report an industrial accident;

4. Assessment of penalty under Section 34A-2-205 against an insurance carrier for improperly notifying the division of coverage written in this state or for this state;

5. Assessment of penalty under Section 34A-2-114 against an employer for unlawfully interfering with an employee's workers' compensation claim.

B. All subsequent adjudicative proceedings in the above-identified matters are designated as formal proceedings.


workers' compensation, administrative procedures

Date of Enactment or Last Substantive Amendment

June 7, 2018

Notice of Continuation

February 8, 2018

Authorizing, 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


For questions regarding the content or application of rules under Title R612, please contact the promulgating agency (Labor Commission, Industrial Accidents). A list of agencies with links to their homepages is available at http://www.utah.gov/government/agencylist.html or from http://www.rules.utah.gov/contact/agencycontacts.htm.