Form 221c Patient's Last Name: Social Security Number: Employer: Phone: Insurance Carrier: Restorative Services Authorization/Denial - LOWER EXTREMITY First: Middle: Date of Birth: Referring Physician: Height: Employer Address: FAX: Provider: Address: Provider Discipline MD Tax ID Number: DO DC PT OT Date of Injury: Weight: Address: Adjuster Name: Phone: Diagnosis Specific to Industrial Claim: FAX: Phone: FAX: Other Conditions or Complicating Factors that May Affect Recovery: List from the patient's essential job functions, measurable objective requirements needed to return to work without restrictions (i.e.: lifting, carrying, grip, reaching overhead, standing or sitting duration, bending, etc.):* Floor-Waist Max Lb. ________ Freq. _______ Waist-Shoulder Max Lb. ________ Freq. _______ Overhead Max Lb. ________ Freq. _______ Carrying Max Lb. ________ Freq. _________ Push/Pull Horizontal force Lb. ________ Functional ROM O=overhead, S=shoulder, H=horizontal, K=knee, F=floor Stairs ________________________________________ 50 ft. speed walk _______________________________ 6 min. walk test ________________________________ Capabilities Recorded on First Visit Date: ___________ Max. Lb____________ Max. Lb.___________ Max. Lb.___________ Max. Lb.____Ft _____ O S H K F Capabilities on 8th Visit Date: __________ Max. Lb.__________ Max. Lb.__________ Max. Lb.__________ Max. Lb. ____Ft ____ O S H K F Capabilities on 14th Visit Date: __________ Max. Lb.__________ Max. Lb.__________ Max. Lb.__________ Max. Lb. ____Ft____ OS H K F Capabilities on 20th Visit Date: __________ Max. Lb.__________ Max. Lb.__________ Max. Lb.__________ Max. Lb. ____Ft____ O S H K F Stairs_____________ 50 ft. ___________sec. 6 min. __________ft. Stairs____________ 50 ft. _________sec. 6 min. ________ ft. Stairs____________ 50 ft. __________sec. 6 min. _________ ft. Stairs____________ 50 ft __________sec. 6 min. ________ ft. LEFS Knee Outcome Hours required to work per shift / Day Patient's Reported Average Pain Intensity (0 to 10 Scale) Hrs working / Day /10 % Manipulation ADL Instruction Hrs working / Day /10 % (Visits 9-14) Hrs working / Day /10 % (Visits 15-20) Hrs working / Day /10 % Visits (21-26) Patient's Reported Average Pain Frequency (% of the Day: 0-10-20-30-40-50-60-70-80-90-100%) Treatment Plan: (Visits 1-8, include frequency) Manual Therapy Therapy Exercise Ultrasound Electrical Stim FCE Testing Neuromuscular Re-education Others (List): Expected number of visits to reach stated functional goals: Attended/Prescribed Visits (Prescribed visits are those that should have been scheduled as per the plan of care) Provider Comments: Provider signature: Payor: Approval for Future Visits Yes Date: No Date: (Visits 9-14) (Visits 15-20) Visits (21-26) Payor Signature: Payor Comments Official Form 221c Revised 7/12 State of Utah * Labor Commission * Division of Industrial Accidents � 160 East 300 South * P O Box 146610 Salt Lake City, UT 84110-6610 * Phone (801) 530-6800 * Fax (801) 530-6804 * Toll Free (800) 530-5090 * www.laborcommission.utah.gov American LegalNet, Inc. www.FormsWorkFlow.com Restorative Services Authorization/Denial - LOWER EXTREMITY Glossary of Terms List the Essential Job Functions: Use specific, functional, and measurable terms (pounds, degrees of motion, length of reach or carry, minutes of tasks, etc.) to describe tasks the individual needs to perform in order to return to their full duty work position. Clinicians can also identify those essential job functions that currently limit the client's ability to perform his or her usual duties. Clinicians are encouraged to discuss the physical demands of the position with both the client and the employer. The job description should then be compared to the client's current physical demands in order to identify the essential job functions that will be used as goals to ascertain whether or not the client is making acceptable progress with the treatment being given in returning to work. The goals should be described in objective, measurable, and functional terms. Examples include: 1) occasional lifts of 30 lbs. from floor to shoulder height, 2) able to perform light assembly work above eye level for up to 20 minutes at one time and 2 � hours a day, 3) able to be up on their feet for up to 2 hours at one time and 6 hours throughout the day and 4) able to type for 45 minutes at one time without increased symptoms." Improvement in stated functional goals, hours worked, and subjective pain ratings will be used to determine whether or not further treatment will be authorized. Patient's Essential Job Functions: Measurable objective requirements to return to work which is listed as maximum weights able to be lifted from floor to waist, waist to shoulder, and to overhead levels; maximum weight able to be carried; and maximum horizontal force to push/pull. Functional Range of Motion: This indicates the ability the individual has to functionally reach overhead, shoulder height, reach out horizontally, to knee height, and to the floor. Stairs: Assess the ability to ascend and descend stairs. 50 Foot Speed Walk: Start the 50-foot walk test (25 feet out and 25 feet back) and the timer on the command "go." The goal is to walk as quickly as possible to the 25 foot mark and back. The timer is stopped when the participant returns to the initial line. A score of 8 seconds to walk 50 feet is considered "normal" pace. 6 Minute Walk Test: This standardized test assesses the ability of an individual to walk as far as possible in six minutes. The test is conducted on a hard, flat surface at a self selected pace. Balance Test: Assess the individual's ability to stand in single-leg stance for 30 seconds and tandem (heel-toe-heel-toe) walking. Balance can also be assessed during functional tasks of climbing, walking, lifting, and carrying. Lower Extremity Functional Scale: This standardized perceived ability questionnaire assesses the ability or difficulty an individual has participating in and completing various daily activities. The following link is a copy of the Lower Extremity Functional Scale and how to score the form: http://www.physio-pedia.com/Lower_Extremity_Functional_Scale_(LEFS) Knee Outcome Survey: This standardized questionnaire includes a survey of activities of daily living (ADLs) and a survey for sports activity. The survey for ADLs is appropriate for individuals who have not returned to sports activity or those who do not engage in recreational sports. The