Get Proposed Rsa Format - Utah Labor Commission - Utah.gov - Laborcommission Utah

Filling out the Proposed RSA Format is a crucial step in the process of obtaining restorative services authorization for upper extremity treatment. This guide provides clear and concise instructions to help you complete the form accurately and efficiently.

Follow the steps to fill out the Proposed RSA Format online.

1. Click the ‘Get Form’ button to access the form and open it in your preferred document editor.
2. Fill in the patient’s last name, first name, and middle initial in the designated fields.
3. Enter the patient's Social Security Number, date of birth, and date of injury accurately to ensure proper identification.
4. Provide the patient's height, weight, employer address, and employer name and phone number.
5. Record the insurance carrier information and details for the referring physician, including their discipline and Tax ID number.
6. In the section regarding conditions affecting recovery, provide any other medical conditions that may influence treatment.
7. Specify the diagnosis relevant to the industrial claim as clearly as possible.
8. List the essential job functions utilizing measurable objective terms, detailing lifting capacities and durations required for the return to work.
9. Document the capabilities recorded during each visit, ensuring to include maximum weight lifted and specific measurements for different ranges of motion.
10. Indicate the hours worked per day and the patient’s reported average pain intensity and frequency.
11. Outline the treatment plan, including the types of therapy intended, and estimate the expected number of visits required for recovery.
12. Add any additional comments or observations from the provider in the space provided to convey relevant information not included elsewhere.
13. Once all sections are completed, review the form for accuracy, save your changes, and then download or print the completed form for submission.

Complete your Proposed RSA Format online to ensure timely authorization and care.