Utah Department of Health and Human Services Forms

This form is used for expediting the placement decision process in accordance with the ICPC regulations in Utah. It ensures compliance with the necessary procedures for placing a child in an expedited manner.

This form is used for requesting a home study in the state of Utah.

This form is used for audiologists in Utah to apply for a harp license.

This form is used for applying for a Harp Child program in Utah. It is designed for parents or guardians to enroll their child in this specific music education program.

This Form is used for requesting prior authorization for medical services or treatments in the state of Utah. It helps ensure that the requested service is medically necessary and covered by the insurance provider.

This form is used for confirming a diagnosis of Autism Spectrum Disorder (ASD) in the state of Utah.

This form is used for requesting prior authorization for hospice services in the state of Utah.

This document is for conducting an independent physician review for extended care at a hospice facility in Utah.

This Form is used for requesting prior authorization for Applied Behavior Analysis (ABA) services in Utah.

This document is a Functional Assessment for a Personal Care Agency in Utah. It helps assess the functional needs of individuals requiring personal care services.

This Form is used for requesting prior authorization for home health and personal care services in Utah.

This Form is used for requesting prior authorization for genetic testing in the state of Utah.

This form is used for conducting the final evaluation of a wheelchair in Utah. It helps assess the functionality and suitability of the wheelchair for the user.

This type of document is a training checklist specifically for power wheelchair training in the state of Utah.

This form is used for obtaining consent for sterilization procedures in the state of Utah. It is available in both English and Spanish languages.

This Form is used for requesting prior authorization for inpatient intensive physical rehabilitation in the state of Utah.

This form is used for requesting prior authorization for mental health residential treatment services for individuals aged 21-64 in Utah.

This Form is used for requesting prior authorization for enteral formula in the state of Utah.

This form is used for requesting prior authorization for individuals aged 21-64 who require psychiatric hospital inpatient services in the state of Utah. It helps ensure that the necessary care and treatment are provided to patients in need.

This document is used for determining the criteria for prior authorization of personal care services in Utah.

This document outlines the terms and conditions for users accessing a service in Utah. It specifies the rights and responsibilities of the user and the service provider.

This form is used for authorizing the release of health information to the Division of Medicaid and Health Financing and the Department of Workforce Services in Utah.

This form is used to request an administrative hearing in Utah.

This Form is used for requesting prior authorization for dental services in the state of Utah. It helps patients and dental providers to obtain approval from insurance companies before undergoing certain dental procedures.

This form is used for requesting prior authorization for durable medical equipment and medical supplies in Utah.

This form is used for requesting prior authorization for physical therapy and occupational therapy services in the state of Utah.

This document is a form to request a replacement check for lost ESI benefits in the state of Utah.

This document is for applying for an Adult Autism Treatment Account in Utah. It provides a summary of the application process and requirements for obtaining funding for autism treatment in adulthood.

This form is used for conducting a health, hearing, and vision assessment in the state of Utah. It helps to evaluate and monitor the overall health and sensory abilities of individuals.

This form is used for reporting birth defects to the Utah Birth Defect Network in Utah.

This form is used for requesting prior authorization for quantity limit exceptions for urine drug screens in the state of Utah.

This Form is used for the initial evaluation of individuals who require a wheelchair in the state of Utah. It helps assess the needs and requirements for a wheelchair to ensure proper fitting and functionality.