Archives: ULC Forms

Workers’ Compensation Poster

Workers' Compensation Poster
Workers’ Compensation Poster

Form 350 – Emergency Medical Service Provider Exposure Report Form

Form 350
Form 350 – Emergency Medical Service Provider Exposure Report Form

Form 302 – Medical Records – Copies

Form 302
Form 302 – Medical Records – Copies

Form 223 – Authorization Request for Medical Procedures/Carrier Response

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

Form 221c – Lower Extremity Restorative Services Authorization/Denial

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

Form 221b – Upper Extremity Restorative Services Authorization/Denial

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

Form 221a – Spine Injury Restorative Services Authorization/Denial

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

Form 219 – Permanent Partial Disability Statement of Compensation

Form 219
Form 219 – Permanent Partial Disability Statement of Compensation

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

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

Form 102 – Application to Change Doctors

Form 102 Revision 7
Form 102 – Application to Change Doctors