Directory Contents

Filename Type Size (bytes) Date Modified
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