Form 221b Patient's Last Name: Social Security Number: Employer: Phone: Insurance Carrier: Restorative Services Authorization/Denial - UPPER EXTREMITY First: Middle: Date of Birth: Referring Physician: Height: Employer Address: FAX: Provider: Address: Date of Injury: Weight: Address: Provider Discipline Tax ID Number: Phone: FAX: MD DO DC PT PT Adjuster Name: Phone: Diagnosis Specific to Industrial Claim: 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 Grip Strength 2nd grip span Pinch Strength 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 ____ O S H K F Capabilities on 20th Visit Date: ___________ Max. Lb.__________ Max. Lb.__________ Max. Lb. __________ Max. Lb. ____Ft ____ O S H K F Max. _____ REG_____ Key_______________ Palmar ____________ Tip ______________ Max. ____ REG_____ Key _____________ Palmar ___________ Tip _____________ Max. ____ REG_____ Key ______________ Palmar ____________ Tip ______________ Max. ____ REG_____ Key______________ Palmar ___________ Tip ______________ Dexterity Test DASH Hand Function Sort 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 221b Revised 7/12 State of Utah * Labor Commission * Division of Industrial Accidents ­ 160 East 300 South * PO Box 146610 Salt Lake City, UT 84114-6610 * Phone 801-530-6800 * Fax 801-530-6804 * American LegalNet, Inc. Toll Free (800) 530-5090 * www.laborcommission.utah.gov www.FormsWorkFlow.com Restorative Services Authorization/Denial - UPPER 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 ½ 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. Grip Strength 2nd Position: Using a grip strength dynamometer at the 2nd position (typically the strongest position) measure the individuals grip strength. Measure three times to assess consistency of efforts. Rapid Exchange Grip (REG): Assessing quick grip strength at the 2nd position on a grip strength dynamometer. Quickly gripping (less than a second in duration) for ten repetitions and measuring the maximum effort. REG efforts that do not exceed maximum efforts of standard grip strength at the 2nd position indicate a valid effort. Invalid efforts result from a REG that exceeds maximal efforts of the standard grip strength at the 2nd position. Pinch Strength: Using a pinch strength dynamometer measure key pinch (thumb against lateral surface of 2nd digit), two-point (thumb against 2nd digit), and three-pinch (thumb against 2nd and 3rd digits.) Measure three times to assess consistency of efforts. Valid efforts will produce a three-point pinch that is stronger than efforts of two-point pinch. Invalid efforts will produce a twopoint pinch that is stronger than efforts of three-point pinch. Purdue Pegboard: This standardized manual dexterity test assesses the ability to manipulate small objects with the fingers, maintain a competitive pace, functional movement, and hand-eye coordination. Includes unilateral, bilateral, and assembly activities. Minnesota Rate of Manipulation: This standardized manual dexterity test assesses the ability to manipulate pegs