Long-Term Care Resources (NFs and ICFs/ID) FCP and FRV Forms

FRV Calculator

Facility Cost Profile (FCP) Forms

These forms are provided for the convenience of nursing home providers in assisting them in their reporting requirements. Questions should be directed to David Meadows of the Bureau of Financial Services.
If you are unsure about an issue, please ask questions.

Please use the 2024 Forms. Old forms/spreadsheets will be returned.

Click cover letter, instructions or forms below.  When prompted select “save” and then navigate to where on your local drive you want to save the file.
Please read the instructions in their entirety before completing the FCP forms. Also, please be sure to carefully review your FCP before submission.
The Related Party Disclosure Statement is only submitted with the FCP if there is not sufficient space on Schedule C-2.

NF Nursing Homes

ICF/ID Nursing Homes

The Related Party Disclosure
‐ is to provide greater understanding of what constitutes related-party compensation and related-party transactions. This form will help assure a common understanding of related-party issues. The end result being that all related-party compensation/transactions will be properly disclosed in accordance with CMS Pub 15-1.

Audited FCP Submissions

NF

ICF/ID

Fair Rental Value (FRV) Data Report Forms

Reminder: This report is optional. If submitted, it must be received no later than the first business day in March.
Failure to do so will preclude the data from being considered.  (No extensions will be granted.)

Please be sure to carefully read and follow the instructions.

Questions should be directed to
David Meadows
(contact information is on the bottom of this page).

FVR Data Report Instructions

FRV Data Report Form

FRV Information Presentation

Long-Term Care Resources (NFs and ICFs/ID)

Please click on one of the following links to be directed to specific resources available for that category:

Nursing Facilities
     - Rates

             - Historical Rates

     - MDS Case Mix Preview Report
     - QI Incentive Programs
     - Non-state Government Owned (NSGO)

          - UPL Program
     - Swing Bed Rates
     - Moratorium and Transfer of NF Beds
     - Additional Resources
ICF/ID
     - Rates
     - Incentive Programs
FCP and FRV Forms

Bed Assessment Rates

Contact Information

FCP and FRV Questions

Via U.S. Post Office

Via UPS or FedEx

801-538-6790
dmeadows@utah.gov

Utah Deparment of Health and Human Services

Division of Integrated Healthcare
Office of Financial Services

PO Box 143104
Salt Lake City, UT 84114-3104

Utah Deparment of Health and Human Services

Division of Integrated Healthcare 
Office of Financial Services
288 North 1460 West
Salt Lake City, UT 84116-3231

If you are unsure about an issue, please ask questions.