Utah Department of Health & Human Services - Integrated Healthcare
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    • Cómo y Dónde Pedir la Asistencia Médica
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    • Provider Training
  • Programs
    • Programs Home
    • Adult Expansion Medicaid
    • Autism Related Services
    • Baby Your Baby
    • Buyout Program
    • Children’s Health Insurance Program
    • Early and Periodic Screening, Diagnostic and Treatment
    • Living Well with Chronic Conditions Program
    • Medicaid for Long-Term Care and Waiver Programs
    • Presumptive Eligibility
    • Primary Care Network
    • Restriction Program
    • Spenddown Program (Medically Needy)
    • Summary of All Medicaid Programs
    • Targeted Adult Medicaid Program
    • Tobacco Cessation Program
    • Traditional and Non-Traditional Medicaid
    • Utah’s Premium Partnership for Health Insurance
  • Administration
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    • UTAH’S MEDICAID REFORM 1115 DEMONSTRATION
    • Boards and Committees
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    • Nondiscrimination Policy
    • One-Time Projects
    • PRISM Info
    • Publications
    • Reporting Fraud
    • UAMRP (Utah Access Monitoring Review Plan)
    • Unwinding Medicaid Continuous Eligibility
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Utah Department of Health and Human Services - Integrated Healthcare

Resident Assessment Forms

Specialized Rehabilitative Services for ID/RC Application

Behaviorally Complex Application

Retroactive Authorization Nursing Facility Request Form

Additional Information Cover Sheet (Submit all additional information with this cover sheet)

Follow us

Headquarters
Multi-Agency State Office Building
195 North 1950 West
Salt Lake City, Ut 84116

For eligibility questions or concerns:
1-866-435-7414

For other questions:
1-866-608-9422

Resources
211Utah - United Way
Safe UT

Hotlines
Abuse/Neglect of Seniors and Adults with Disabilities
1-800-371-7897

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

Crisis Line & Mobile Outreach Team
1-801-587-3000

National Suicide Prevention Lifeline
1-800-273-TALK(8255)

Sexual Violence Crisis Line
1-888-421-1100

Utah Domestic Violence
1-800-897-LINK(5465)

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  • Apply
    • Apply for Medicaid
    • Apply for Baby Your Baby
    • Cómo y Dónde Pedir la Asistencia Médica
  • Members
    • Members Home
    • Additional Information
    • Language Services
    • Nondiscrimination Policy
    • Programs and Services
    • Providers
    • Resources
    • MyBenefits Login
  • Providers
    • Providers Home
    • PRISM Info
    • PRISM Portal Access
    • Become a Medicaid Provider
    • Claims
    • Coverage and Reimbursement
    • Managed Care
    • Medicaid Pharmacy Program
    • Patient Eligibility Verification
    • Presumptive Eligibility Portal Access
    • Prior Authorization
    • Provider Resources and Information
    • Provider Training
  • Programs
    • Programs Home
    • Adult Expansion Medicaid
    • Autism Related Services
    • Baby Your Baby
    • Buyout Program
    • Children’s Health Insurance Program
    • Early and Periodic Screening, Diagnostic and Treatment
    • Living Well with Chronic Conditions Program
    • Medicaid for Long-Term Care and Waiver Programs
    • Presumptive Eligibility
    • Primary Care Network
    • Restriction Program
    • Spenddown Program (Medically Needy)
    • Summary of All Medicaid Programs
    • Targeted Adult Medicaid Program
    • Tobacco Cessation Program
    • Traditional and Non-Traditional Medicaid
    • Utah’s Premium Partnership for Health Insurance
  • Administration
    • Administration Home
    • UTAH’S MEDICAID REFORM 1115 DEMONSTRATION
    • Boards and Committees
    • HIPAA
    • Hearings
    • Medicaid Expansion
    • Medicaid State Plan
    • Nondiscrimination Policy
    • One-Time Projects
    • PRISM Info
    • Publications
    • Reporting Fraud
    • UAMRP (Utah Access Monitoring Review Plan)
    • Unwinding Medicaid Continuous Eligibility
  • ESPAÑOL
  • Search