No. 38811 (Amendment): Section R612-100-3. Official Forms

(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 Commission
Industrial 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 [e-mail]

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.

 

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