Form 221a Patient's Last Name: Social Security Number: Employer: Phone: Insurance Carrier: Address: Restorative Services Authorization/Denial - SPINE First: Middle: Date of Birth: Referring Physician: Height: Employer Address: FAX: Provider: Address: Provider Discipline Tax ID Number: Phone: FAX: Date of Injury: Weight: MD DO DC PT OT Adjuster Name: Phone: Diagnosis Specific to Industrial Claim: 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 Sitting tolerance Min. Standing tolerance Min. Squat/stoop/bend Min. Capabilities Recorded on First Visit Date: Max. Lb. Max. Lb. Max. Lb. Max. Lb. FAX: Other Conditions or Complicating Factors that May Affect Recovery: Capabilities on 8th Visit Date: Max. Lb. Max. Lb. Max. Lb. Max. Lb. Capabilities on 14th Visit Date: Max. Lb. Max. Lb. Max. Lb. Max. Lb. Capabilities on 20th Visit Date: Max. Lb. Max. Lb. Max. Lb. Max. Lb. Ft Ft Ft Ft O S H K F Min. Min. Min. O S H K F Min. Min. Min. O S H K F Min. Min. Min. O S H K F Min. Min. Min. Modified Oswestry Disability Questionnaire Neck Disability Index Hours required to work per shift / Day Patient's Reported Average Pain Intensity (0 to 10 Scale) Patient's Reported Average Pain Frequency (% of the Day: 0-10-20-30-40-50-60-70-80-90-100%) Hrs working / Day /10 % Hrs working / Day /10 % (Visits 9-14) Hrs working / Day /10 % (Visits 15-20) Hrs working / Day /10 % Visits (21-26) Treatment Plan: (Visits 1-8, include frequency) Manual Therapy Manipulation Therapy Exercise Ultrasound Electrical Stim FCE Testing ADL Instruction 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 Payor Signature: Payor Comments Date: Yes No Date: (Visits 9-14) (Visits 15-20) Visits (21-26) Official Form 221a Revised 7/12 State of Utah * Labor Commission * Division of Industrial Accidents � 160 East 300 South * P O Box 146610 * Salt Lake City, UT 84114-6610 * 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 � SPINE 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: 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. Sitting/Standing tolerance: Ability to sustain functional sitting or standing. Squat/Stoop/Bend: Squat (knee bend with upright trunk posture), stoop (combination of flexed knees and forward flexed torso), and bend (forward lumbar flexion) Modified Oswestry Disability Questionnaire: The Modified Oswestry Disability Questionnaire is a standardized perceived ability assessment for daily tasks, ability to assume various postures, pain intensity, work tasks and recreational activities. This questionnaire is primarily used for the lumbar spine. The following link is a copy of the Modified Oswestry Disability Questionnaire and how to score the form: http://laborcommission.utah.gov/media/pdfs/industrialaccidents/forms/oswestry_disability_index.pdf Neck Disability Index: The Neck Disability Index is a standardized perceived ability assessment for daily tasks, ability to assume various postures, pain intensity, work tasks and recreational activities. This questionnaire is primarily used for the cervical spine. The following link is a copy of the Neck Disability Questionnaire and how to score the form: http://laborcommission.utah.gov/media/pdfs/industrialaccidents/forms/neck_disability_index.pdf Quadruple Visual Analog Scale: The Quadruple Analog Scale is a standardized assessment for reported pain intensity. This questionnaire asks the intensity of pain at the best, at the worst, on average or most typical, and at the current time. The following link is a copy of the Quadruple Visual Analog Scalehttp://laborcommission.utah.gov/media/pdfs/industrialaccidents/forms/quadruple_vas_2.pdf Hours Required to Work Per Shift/Day: This should reflect the pre-injury average hours required per shift the patient was required to work for a full day's work. On the 8, 14 and 20th visits, list the average numbers of hours per day the individual is currently working. Pain Intensity: The individual will rate their pain on a 10 centimeter visual analog scale with "0" bei