Resident Assessment Forms

DHHS Retroactive Authorization Request Form for Nursing Facilities and ICFs

DHHS Freedom of Choice Form for ICFs

DHHS Medically Complex Services Application for ICFs

DHHS Cognitive Dysfunction Attestation for Nursing Facilities and Waivers

DHHS Specialized Rehabilitative Services Application for Nursing Facilities

DHHS Behaviorally Complex Tier 1 Application for Nursing Facilities

DHHS Behaviorally Complex Tier 2 Application for Nursing Facilities

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Utah Department of Health and Human Services Integrated Healthcare
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Cannon Health Building
288 North 1460 West
Salt Lake City, UT
84116
Contact Us
 
For eligibility questions or concerns:
1-866-435-7414
For other questions:
1-866-608-9422
 
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1-800-371-7897

Child Abuse/Neglect
1-855-323-DCFS(3237)

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1-801-587-3000

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1-800-273-TALK(8255)

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1-888-421-1100

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1-800-897-LINK(5465)

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