| 2021-04-05_Utah_Medicaid_Initial_Wheelchair_Evaluation_Form.docx |
2021-04-05_UTAH_MEDICAID_INITIAL_WHEELCHAIR_EVALUATION_FORM.DOCX File |
89,590 |
Sep 15 2021 2:18 PM |
| 2021-04-05_Utah_Medicaid_Initial_Wheelchair_Evaluation_Form.pdf |
2021-04-05_UTAH_MEDICAID_INITIAL_WHEELCHAIR_EVALUATION_FORM.PDF File |
1,444,972 |
Sep 15 2021 2:18 PM |
| Abortionacknowledge7-12.pdf |
ABORTIONACKNOWLEDGE7-12.PDF File |
349,118 |
May 21 2021 10:07 AM |
| AgreementFinancial.pdf |
AGREEMENTFINANCIAL.PDF File |
118,280 |
May 21 2021 10:07 AM |
| Applied Behavioral Analysis (ABA) Services Prior Authorization Form Fillable.pdf |
APPLIED BEHAVIORAL ANALYSIS (ABA) SERVICES PRIOR AUTHORIZATION FORM FILLABLE.PDF File |
344,564 |
May 21 2021 10:07 AM |
| Authorization_DisclosePHI2018.pdf |
AUTHORIZATION_DISCLOSEPHI2018.PDF File |
36,388 |
May 21 2021 10:07 AM |
| Authorization_To_DisclosePHI2016.pdf |
AUTHORIZATION_TO_DISCLOSEPHI2016.PDF File |
20,691 |
May 21 2021 10:07 AM |
| AutismDiagForm1-18.pdf |
AUTISMDIAGFORM1-18.PDF File |
146,125 |
May 21 2021 10:07 AM |
| Client_request_PHI2018.pdf |
CLIENT_REQUEST_PHI2018.PDF File |
17,453 |
May 21 2021 10:07 AM |
| CombiningAdmission.pdf |
COMBININGADMISSION.PDF File |
80,508 |
May 21 2021 10:07 AM |
| Dental Prior Authorization Request Form.pdf |
DENTAL PRIOR AUTHORIZATION REQUEST FORM.PDF File |
252,489 |
Jul 21 2021 3:38 PM |
| DentalAgreement.pdf |
DENTALAGREEMENT.PDF File |
298,285 |
May 21 2021 10:07 AM |
| Disclosure-ClientRequest.pdf |
DISCLOSURE-CLIENTREQUEST.PDF File |
11,470 |
May 21 2021 10:07 AM |
| DisclosureFromHCF.pdf |
DISCLOSUREFROMHCF.PDF File |
15,226 |
May 21 2021 10:07 AM |
| DisclosureToHCF.pdf |
DISCLOSURETOHCF.PDF File |
15,122 |
May 21 2021 10:07 AM |
| DocSubmission4-18.pdf |
DOCSUBMISSION4-18.PDF File |
112,004 |
May 21 2021 10:07 AM |
| DonorMilkForm1-15.pdf |
DONORMILKFORM1-15.PDF File |
237,216 |
May 21 2021 10:07 AM |
| Durable Medical Equipment and Medical Supplies Prior Authorization Request Form Fillable.pdf |
DURABLE MEDICAL EQUIPMENT AND MEDICAL SUPPLIES PRIOR AUTHORIZATION REQUEST FORM FILLABLE.PDF File |
314,758 |
Jul 1 2021 8:39 AM |
| EmergServicesDocSubmission8-20.pdf |
EMERGSERVICESDOCSUBMISSION8-20.PDF File |
275,807 |
May 21 2021 10:07 AM |
| Enteral Formula Prior Authorization Request Form Fillable.pdf |
ENTERAL FORMULA PRIOR AUTHORIZATION REQUEST FORM FILLABLE.PDF File |
237,684 |
May 21 2021 10:07 AM |
| Food_Lodging10-11.pdf |
FOOD_LODGING10-11.PDF File |
315,609 |
May 21 2021 10:07 AM |
| GenMedForm.pdf |
GENMEDFORM.PDF File |
32,332 |
May 21 2021 10:07 AM |
| General Prior Authorization Request Form Fillable.pdf |
GENERAL PRIOR AUTHORIZATION REQUEST FORM FILLABLE.PDF File |
284,482 |
May 21 2021 10:07 AM |
| Genetic Testing Prior Authorization Request Form Fillable.pdf |
GENETIC TESTING PRIOR AUTHORIZATION REQUEST FORM FILLABLE.PDF File |
268,938 |
May 21 2021 10:07 AM |
| HearingRequest2020.pdf |
HEARINGREQUEST2020.PDF File |
873,317 |
May 21 2021 10:07 AM |
| HearingRequestSpanish2019.pdf |
HEARINGREQUESTSPANISH2019.PDF File |
187,128 |
May 21 2021 10:07 AM |
| Home Health and Personal Care Prior Authorization Request Form Fillable.pdf |
HOME HEALTH AND PERSONAL CARE PRIOR AUTHORIZATION REQUEST FORM FILLABLE.PDF File |
267,590 |
May 21 2021 10:07 AM |
| Homehealth60day.pdf |
HOMEHEALTH60DAY.PDF File |
31,384 |
May 21 2021 10:07 AM |
| Hospice Services Prior Authorization Request Form Fillable.pdf |
HOSPICE SERVICES PRIOR AUTHORIZATION REQUEST FORM FILLABLE.PDF File |
253,025 |
May 21 2021 10:07 AM |
| HospiceExtendedCare.pdf |
HOSPICEEXTENDEDCARE.PDF File |
358,438 |
May 21 2021 10:07 AM |
| HospiceSIA.pdf |
HOSPICESIA.PDF File |
173,127 |
May 21 2021 10:07 AM |
| HysterectomyAcknowledgment10-14.pdf |
HYSTERECTOMYACKNOWLEDGMENT10-14.PDF File |
428,931 |
May 21 2021 10:07 AM |
| HysteroDeviceChecklist1-14.pdf |
HYSTERODEVICECHECKLIST1-14.PDF File |
425,080 |
May 21 2021 10:07 AM |
| ICF Freedom of Choice Acknowledgement.pdf |
ICF FREEDOM OF CHOICE ACKNOWLEDGEMENT.PDF File |
75,114 |
Sep 24 2021 9:16 AM |
| ICF and Community Supports Waiver FACT sheet.pdf |
ICF AND COMMUNITY SUPPORTS WAIVER FACT SHEET.PDF File |
135,719 |
Nov 22 2021 11:23 AM |
| Inpatient Intensive Physical Rehabilitation Prior Authorization Request Form Fillable.pdf |
INPATIENT INTENSIVE PHYSICAL REHABILITATION PRIOR AUTHORIZATION REQUEST FORM FILLABLE.PDF File |
249,858 |
May 21 2021 10:07 AM |
| Mental Health Residential Treatment Services- Individuals Age 21-64 Prior Authorization Request Form Fillable.pdf |
MENTAL HEALTH RESIDENTIAL TREATMENT SERVICES- INDIVIDUALS AGE 21-64 PRIOR AUTHORIZATION REQUEST FORM FILLABLE.PDF File |
251,590 |
May 21 2021 10:07 AM |
| Nursing Facility Behaviorally Complex Application.pdf |
NURSING FACILITY BEHAVIORALLY COMPLEX APPLICATION.PDF File |
54,428 |
May 21 2021 10:07 AM |
| Nursing Facility Specialized Rehab Services Application.pdf |
NURSING FACILITY SPECIALIZED REHAB SERVICES APPLICATION.PDF File |
262,249 |
May 21 2021 10:07 AM |
| Out_of_StateTravel10-20.pdf |
OUT_OF_STATETRAVEL10-20.PDF File |
1,968,845 |
May 21 2021 10:07 AM |
| PDN-Grid(printable)4-13.pdf |
PDN-GRID(PRINTABLE)4-13.PDF File |
191,841 |
May 21 2021 10:07 AM |
| PPC_Doc_Submission_Form10-17.pdf |
PPC_DOC_SUBMISSION_FORM10-17.PDF File |
210,323 |
May 21 2021 10:07 AM |
| PRISM-SEC-AGRMNT.pdf |
PRISM-SEC-AGRMNT.PDF File |
275,056 |
May 27 2021 12:04 PM |
| PT_OTRehabAgreement.pdf |
PT_OTREHABAGREEMENT.PDF File |
26,215 |
May 21 2021 10:07 AM |
| PaymentAdjustment.pdf |
PAYMENTADJUSTMENT.PDF File |
224,666 |
May 21 2021 10:07 AM |
| PaymentAdjustmentPharmacy.pdf |
PAYMENTADJUSTMENTPHARMACY.PDF File |
391,907 |
May 21 2021 10:07 AM |
| PersonalCareCapitated1-12.pdf |
PERSONALCARECAPITATED1-12.PDF File |
269,029 |
May 21 2021 10:07 AM |
| PersonalCareFunctionalAssess1-18.pdf |
PERSONALCAREFUNCTIONALASSESS1-18.PDF File |
111,725 |
May 21 2021 10:07 AM |
| PersonalCareWorksheet1-18.pdf |
PERSONALCAREWORKSHEET1-18.PDF File |
132,971 |
May 21 2021 10:07 AM |
| Physical Therapy and Occupational Therapy Prior Authorization Request Form Fillable.pdf |
PHYSICAL THERAPY AND OCCUPATIONAL THERAPY PRIOR AUTHORIZATION REQUEST FORM FILLABLE.PDF File |
329,967 |
Jul 1 2021 8:39 AM |
| PrivateDutyNursingGrid4-13.xls |
PRIVATEDUTYNURSINGGRID4-13.XLS File |
155,136 |
May 21 2021 10:07 AM |
| ProviderAgreement.pdf |
PROVIDERAGREEMENT.PDF File |
81,478 |
May 21 2021 10:07 AM |
| RadiationDosimetryForm4-14.pdf |
RADIATIONDOSIMETRYFORM4-14.PDF File |
371,823 |
May 21 2021 10:07 AM |
| RemittanceAdviceRequest11-21.pdf |
REMITTANCEADVICEREQUEST11-21.PDF File |
39,284 |
Nov 26 2021 2:59 PM |
| RetroAuthNF_Request.pdf |
RETROAUTHNF_REQUEST.PDF File |
52,920 |
May 21 2021 10:07 AM |
| SkilledNurseForm1-10.pdf |
SKILLEDNURSEFORM1-10.PDF File |
83,053 |
May 21 2021 10:07 AM |
| SterilizationConsent8-20.pdf |
STERILIZATIONCONSENT8-20.PDF File |
483,470 |
May 21 2021 10:07 AM |
| SterilizationConsentSpanish8-20.pdf |
STERILIZATIONCONSENTSPANISH8-20.PDF File |
431,257 |
May 21 2021 10:07 AM |
| Substance Use Disorder Residential Treatment Services Prior Authorization Request Form.pdf |
SUBSTANCE USE DISORDER RESIDENTIAL TREATMENT SERVICES PRIOR AUTHORIZATION REQUEST FORM.PDF File |
361,116 |
Dec 1 2021 1:43 PM |
| Urine Drug Screen Prior Authorization Request for Quantity Limit Exceptions Fillable.pdf |
URINE DRUG SCREEN PRIOR AUTHORIZATION REQUEST FOR QUANTITY LIMIT EXCEPTIONS FILLABLE.PDF File |
281,112 |
Jul 21 2021 3:41 PM |
| WarrantRequest1-22.pdf |
WARRANTREQUEST1-22.PDF File |
213,241 |
Feb 1 2022 4:34 PM |
| WheelchairChecklist10-19.pdf |
WHEELCHAIRCHECKLIST10-19.PDF File |
173,442 |
May 21 2021 10:07 AM |
| WheelchairForm1-20.pdf |
WHEELCHAIRFORM1-20.PDF File |
111,178 |
May 21 2021 10:07 AM |
| eMIPP_Coversheet.pdf |
EMIPP_COVERSHEET.PDF File |
674,975 |
May 21 2021 10:07 AM |
| eMIPP_Coversheet_09152016.pdf |
EMIPP_COVERSHEET_09152016.PDF File |
1,088,651 |
May 21 2021 10:07 AM |