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Utah Forms

15 State Forms found

name	number	revision	print or send online
ATTENDING PHYSICIAN'S STATEMENT	Form 043	Rev 10/2019
APPLICATION TO CHANGE DOCTORS	Form 102	Rev 07/2024
Authorization Request for Medical Treatment / Carrier Response	Form 223	Rev 7/2024
AUTHORIZATION TO DISCLOSE, RELEASE AND USE PROTECTED HEALTH INFORMATION (10 YEARS OF RECORDS) HIPAA COMPLIANT	Form 308	6.12.2020
AUTHORIZATION TO RELEASE INDUSTRIAL ACCIDENT DIVISION RECORDS	Form 205	Revised 3/2020
Emergency Medical Service Provider Exposure Report Form	Form 350	Revised 8/2012
REQUEST FOR MEDICAL RECORDS	Form 302	Rev 10/2019
NOTICE OF ALLEGED WORKPLACE SAFETY AND/OR HEALTH VIOLATIONS	No Form Number	(Rev. 9/2011)
SUMMARY OF MEDICAL RECORD – INDUSTRIAL ACCIDENT	Form 113a	Revised 3/2010
SUMMARY OF MEDICAL RECORD – OCCUPATIONAL EXPOSURE	Form 113b	Revised 3/2010
MEDICAL TREATMENT PROVIDER LIST	Form 307	Revised 01/21
Restorative Services Authorization / Denial - SPINE	Form 221a	Rev 7/2024
Restorative Services Authorization/Denial - UPPER EXTREMITY	Form 221b	Rev 7/2024
Restorative Services Authorization/Denial - LOWER EXTREMITY	Form 221c	Rev 7/2024
AUTHORIZATION TO DISCLOSE, RELEASE AND USE PROTECTED HEALTH INFORMATION PERMANENT TOTAL DISABILTY CLAIMS (15 YEARS OF RECORDS) HIPAA COMPLIANT	Form 308	6.12.2020

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Disclaimer: These forms may not be the most recent version. Utah may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on this site. Please check official sources.

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