Utah Department of Health and Human Services Forms

This document is used for self-administered services agreements in the state of Utah. It outlines the terms and conditions for self-administering certain services.

This form is used to certify the divorce, dissolution of marriage, or annulment in the state of Utah.

This document provides a pregnancy weight gain chart in pounds specifically for residents in Utah. It guides expectant mothers on healthy weight gain during pregnancy.

This Form is used for obtaining consent from individuals in Utah for a Tuberculin Skin Test, a common diagnostic test for tuberculosis.

This Form is used for applying for Special Rehabilitation Services for individuals with intellectual disabilities or related conditions in Utah.

This document is a checklist form used in Utah to prepare for a home visit by foster care providers. It helps ensure that all necessary requirements and preparations are completed before the visit takes place.

This document is used for recording and tracking the administration of medications in the state of Utah.

This document is used for reporting incidents that occur in the state of Utah. It helps to document and provide details about the event, such as the date, time, location, and description of what happened.

This form is used to record and document the orientation training of employees in Utah.

This form is used for keeping track of an individual's competency training in the state of Utah. It allows employers and employees to document completed training courses and certifications.

This document records the inservice training of employees in Utah. It tracks the training sessions attended and the skills acquired by the employees.

This document is used for a negotiated risk contract in the state of Utah. It outlines the terms and conditions of a contract that involves assuming some level of risk and liability.

This form is used for keeping a record of medications taken in the state of Utah. It helps individuals track their medication history and provides valuable information to healthcare providers.

This document is used for assessing the residents in Type I & II Assisted Living Facilities in Utah. It helps determine the care and assistance needed for each resident.

This document is used for filing an initial entity report in the state of Utah. It is a required form for new businesses or entities to provide basic information about their structure and ownership.

This document is a survey specific to assisted living facilities in Utah. It is used to gather feedback and information about the quality of care and services provided in these facilities.

This document is used to make decisions about life-sustaining treatment in Utah. It is a directive that ensures individuals receive the desired medical care and maintain their dignity in critical situations.

This Form is used for applying for medical services in Utah.

This form is used for employers in Utah to provide health insurance information. It is required by the Department of Health (DOH) and helps ensure that employees have access to the necessary health insurance coverage.

This document is a tool used in Utah to attest compliance with the Home and Community-Based Services (HCBS) Settings Rule for residential settings.

This Form is used for reporting medication errors in the state of Utah.

This form is used for health insurance enrollment in the state of Utah. It provides information about the individual's health insurance coverage details.

This document is used for requesting a one-time payment from the Utah Department of Child and Family Services (DCFS). It is an application form that individuals can fill out to request financial assistance for a specific need or emergency situation.

This type of document is a service invoice that is used in the state of Utah. It is used by service providers to bill their customers for the services they have provided. The invoice includes details such as the service description, quantity, rate, and total amount due.

This Form is used for setting up Direct Deposit/Electronic Funds Transfer (EFT) for CAPS Provider Billings in Utah. It allows for convenient and secure transfer of funds electronically.

This document is an agreement used in Utah to file a loss affidavit in cases of stolen or lost property.

This Form is used for acknowledging and certifying abortion in the state of Utah.

This document is a checklist for healthcare providers in Utah Medicaid for the use of hysteroscopic tubal occlusive devices. It provides a step-by-step guide to ensure proper documentation and qualification for this procedure.