Forms

Prior Authorization Request Form

Abortion Acknowledgment Form

Durable Medical Equipment Repair or Replacement Information

Genetic Testing Additional Information Form

Hospice Admission Record

Hysterectomy Acknowledgment Form

Modification Request Form

Out of State Travel Form

Private Duty Nursing Acuity Grid

Private Duty Nursing Acuity Grid (Printable)

Sterilization Consent Form

Sterilization Consent Form (Spanish)

Targeted Adult Medicaid – Substance Use Disorder Treatment Verification Form for Dental Services

Urine Drug Screen Information Form

Utah Medicaid Prior Authorization Modification Request Form

Wheelchair Initial Evaluation Form

Wheelchair Initial Evaluation Form (Printable)

Wheelchair Final Evaluation Form

Wheelchair Training Checklist (Power Wheelchair)