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

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 2023 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

Instructions FY23 (Word Document)
Forms FY23 (Excel Spreadsheet)
Related Party Disclosure Statement opens in a new tab

ICF/ID Nursing Homes

Instructions FY23 (Word Document)
Forms FY23 (Excel Spreadsheet)
Related Party Disclosure Statement opens in a new tab

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
2015	2015
2016	2016
2017	2017
2018	2018
2019	2019
2020	2020
2021	2021
2022	2022

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
email David Meadows
(contact information is on the bottom of this page).

FVR Data Report Instructions opens in a new tab

FRV Data Report Form

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 - FRV Calculator - MDS Case Mix Preview Report - QI Incentive Programs - Non-state Government Owned (NSGO) - UPL Program - Quality Improvement 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
David Meadows 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.