Archives: ULC Forms

Form 223 – Authorization Request for Medical Procedures/Carrier Response

Form 223 - Authorization Request for Medical Procedures/Carrier Response
Form 223 – Authorization Request for Medical Procedures/Carrier Response

Form 221c – Lower Extremity Restorative Services Authorization/Denial

Form 221c - Lower Extremity Restorative Services Authorization/Denial
Form 221c – Lower Extremity Restorative Services Authorization/Denial

Form 221b – Upper Extremity Restorative Services Authorization/Denial

Form 221b - Upper Extremity Restorative Services Authorization/Denial
Form 221b – Upper Extremity Restorative Services Authorization/Denial

Form 221a – Spine Injury Restorative Services Authorization/Denial

Form 221a - Spine Injury Restorative Services Authorization/Denial
Form 221a – Spine Injury Restorative Services Authorization/Denial

Form 219 – Permanent Partial Disability Statement of Compensation

Form 219 - Permanent Partial Disability Statement of Compensation
Form 219 – Permanent Partial Disability Statement of Compensation

Form 123 – Physician’s Initial Report of Work Injury or Occupational Disease

Form 123 - Physician's Initial Report of Work Injury or Occupational Disease
Form 123 – Physician’s Initial Report of Work Injury or Occupational Disease

Form 102 – Application to Change Doctors

Form 102 - Application to Change Doctors
Form 102 – Application to Change Doctors

Form 044 – Employee’s Notification of Intent to Leave Locality or State, and to Change Doctor or Hospital

Form 044 - Employee's Notification of Intent to Leave Locality or State, and to Change Doctor or Hospital
Form 044 – Employee’s Notification of Intent to Leave Locality or State, and to Change Doctor or Hospital

Form 043 – Attending Physician’s Statement

Form 043 - Attending Physician's Statement
Form 043 – Attending Physician’s Statement

Elevator Inspection Request

Elevator Inspection Request Form
Elevator Inspection Request