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 188,190 May 30 2024 10:06 AM
2021-04-05_Utah_Medicaid_Initial_Wheelchair_Evaluation_Form.pdf 2021-04-05_UTAH_MEDICAID_INITIAL_WHEELCHAIR_EVALUATION_FORM.PDF File 279,923 May 30 2024 10:08 AM
2023-07 Medical Review Form - Out of State Travel Request.pdf 2023-07 MEDICAL REVIEW FORM - OUT OF STATE TRAVEL REQUEST.PDF File 781,303 Dec 29 2023 11:04 AM
Abortion Acknowledgement Form.pdf ABORTION ACKNOWLEDGEMENT FORM.PDF File 188,343 Sep 20 2024 2:06 PM
AgreementFinancial.pdf AGREEMENTFINANCIAL.PDF File 118,280 Sep 21 2022 8:35 AM
Authorization_DisclosePHI2018.pdf AUTHORIZATION_DISCLOSEPHI2018.PDF File 36,388 Sep 21 2022 8:35 AM
Authorization_To_DisclosePHI2016.pdf AUTHORIZATION_TO_DISCLOSEPHI2016.PDF File 20,691 Sep 21 2022 8:35 AM
Behaviorally complex application.pdf BEHAVIORALLY COMPLEX APPLICATION.PDF File 122,522 Sep 9 2024 12:22 PM
CONSENTIMIENTO PARA LA ESTERILIZACIÓN.pdf CONSENTIMIENTO PARA LA ESTERILIZACIÓN.PDF File 131,432 Sep 21 2022 8:35 AM
Client_request_PHI2018.pdf CLIENT_REQUEST_PHI2018.PDF File 17,453 Sep 21 2022 8:35 AM
CombiningAdmission.pdf COMBININGADMISSION.PDF File 80,508 Sep 21 2022 8:35 AM
Consent for Sterilization_ Form HHS-687.pdf CONSENT FOR STERILIZATION_ FORM HHS-687.PDF File 128,589 Sep 21 2022 8:35 AM
DME Repair_Replacement Info.pdf DME REPAIR_REPLACEMENT INFO.PDF File 90,688 Aug 10 2023 9:19 AM
DentalAgreement.pdf DENTALAGREEMENT.PDF File 390,638 Aug 8 2024 3:59 PM
Disclosure-ClientRequest.pdf DISCLOSURE-CLIENTREQUEST.PDF File 11,470 Sep 21 2022 8:35 AM
DisclosureFromHCF.pdf DISCLOSUREFROMHCF.PDF File 15,226 Sep 21 2022 8:35 AM
DisclosureToHCF.pdf DISCLOSURETOHCF.PDF File 15,122 Sep 21 2022 8:35 AM
DonorMilkForm1-15.pdf DONORMILKFORM1-15.PDF File 237,216 Sep 21 2022 8:35 AM
Freedom of Choice Acknowledgement.pdf FREEDOM OF CHOICE ACKNOWLEDGEMENT.PDF File 89,324 Oct 4 2024 10:50 AM
GenMedForm.pdf GENMEDFORM.PDF File 32,332 Sep 21 2022 8:35 AM
General PA form.pdf GENERAL PA FORM.PDF File 256,892 Feb 1 2023 12:19 PM
Genetic Testing Additional Info.pdf GENETIC TESTING ADDITIONAL INFO.PDF File 142,567 Nov 3 2023 12:28 PM
HearingRequest2023.pdf HEARINGREQUEST2023.PDF File 213,878 Sep 22 2023 4:10 PM
HearingRequestSpanish2019.pdf HEARINGREQUESTSPANISH2019.PDF File 187,128 Sep 21 2022 8:35 AM
Homehealth60day.pdf HOMEHEALTH60DAY.PDF File 31,384 Sep 21 2022 8:35 AM
HysterectomyAcknowledgment_Fillable.pdf HYSTERECTOMYACKNOWLEDGMENT_FILLABLE.PDF File 122,998 Sep 19 2024 10:41 AM
Medicaid Final Wheelchair Evalaution Form.pdf MEDICAID FINAL WHEELCHAIR EVALAUTION FORM.PDF File 193,675 Apr 22 2024 10:19 AM
Medically complex services application.pdf MEDICALLY COMPLEX SERVICES APPLICATION.PDF File 142,596 Sep 9 2024 12:23 PM
Modification Request Form.pdf MODIFICATION REQUEST FORM.PDF File 199,924 Nov 3 2023 12:28 PM
PPC_Doc_Submission_Form4-23.pdf PPC_DOC_SUBMISSION_FORM4-23.PDF File 430,333 Apr 18 2023 4:06 PM
PRISM-SEC-AGRMNT.pdf PRISM-SEC-AGRMNT.PDF File 293,350 Sep 18 2023 4:06 PM
PT_OTRehabAgreement.pdf PT_OTREHABAGREEMENT.PDF File 26,215 Sep 21 2022 8:35 AM
PaymentAdjustment7-24.pdf PAYMENTADJUSTMENT7-24.PDF File 71,148 Jun 27 2024 11:13 AM
PaymentAdjustmentPharmacy.pdf PAYMENTADJUSTMENTPHARMACY.PDF File 391,907 Sep 21 2022 8:35 AM
PersonalCareCapitated1-12.pdf PERSONALCARECAPITATED1-12.PDF File 269,029 Sep 21 2022 8:35 AM
PrivateDutyNursingGrid.pdf PRIVATEDUTYNURSINGGRID.PDF File 439,150 Oct 22 2024 12:00 PM
PrivateDutyNursingGrid.xlsx PRIVATEDUTYNURSINGGRID.XLSX File 103,881 Oct 22 2024 3:33 PM
ProviderAgreement.pdf PROVIDERAGREEMENT.PDF File 81,478 Sep 21 2022 8:35 AM
RadiationDosimetryForm4-14.pdf RADIATIONDOSIMETRYFORM4-14.PDF File 371,823 Sep 21 2022 8:35 AM
RemittanceAdviceRequest11-21.pdf REMITTANCEADVICEREQUEST11-21.PDF File 39,284 Sep 21 2022 8:35 AM
Retroactive authorization request form.pdf RETROACTIVE AUTHORIZATION REQUEST FORM.PDF File 386,004 Sep 9 2024 12:23 PM
SkilledNurseForm1-10.pdf SKILLEDNURSEFORM1-10.PDF File 83,053 Sep 21 2022 8:35 AM
Specialized rehabilitative services application.pdf SPECIALIZED REHABILITATIVE SERVICES APPLICATION.PDF File 138,856 Sep 9 2024 12:23 PM
TAM SUD Verification Form - Dental.pdf TAM SUD VERIFICATION FORM - DENTAL.PDF File 177,204 Nov 3 2023 12:27 PM
TimelyFiling_Doc_Submission_Form4-23.pdf TIMELYFILING_DOC_SUBMISSION_FORM4-23.PDF File 197,666 Apr 18 2023 4:06 PM
Urine Drug Testing Info.pdf URINE DRUG TESTING INFO.PDF File 191,643 Nov 3 2023 12:27 PM
WarrantRequest1-22.pdf WARRANTREQUEST1-22.PDF File 213,241 Sep 21 2022 8:35 AM
WheelchairChecklist10-19.pdf WHEELCHAIRCHECKLIST10-19.PDF File 261,641 Apr 22 2024 10:20 AM
WheelchairForm1-20.pdf WHEELCHAIRFORM1-20.PDF File 111,178 Sep 21 2022 8:35 AM
eMIPP_Coversheet.pdf EMIPP_COVERSHEET.PDF File 674,975 Sep 21 2022 8:35 AM
eMIPP_Coversheet_09152016.pdf EMIPP_COVERSHEET_09152016.PDF File 1,088,651 Sep 21 2022 8:35 AM