Utah Medicaid Forms

The forms below are updated on a bimonthly basis when necessary. They have been alphabetized for your convenience. If you have questions, contact the webmaster or call Medicaid Information at (801) 538-6155 or 1-800-662-9651.

If you are a Medicaid member, you can access literature, forms, and other publications at the Utah Medical Benefits website; click here opens in a new tab.

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If you have comments or questions, need hard copies or archived official Medicaid materials, please email [email protected].

Directory contents

Documents/pdfs/Forms/

NameTypeLast Modified
Download fileAbortion Acknowledgement Form.pdfFile02/25/2025
Download fileAgreementFinancial.pdfFile02/25/2025
Download fileCONSENTIMIENTO PARA LA ESTERILIZACIÓN.pdfFile02/25/2025
Download fileConsent for Sterilization_ Form HHS-687.pdfFile02/25/2025
Download fileDHHS Behaviorally Complex Tier 1 Application for Nursing Facilities.pdfFile04/02/2026
Download fileDHHS Behaviorally Complex Tier 2 Application for Nursing Facilities.pdfFile04/02/2026
Download fileDHHS Cognitive Dysfunction Attestation for Nursing Facilities and Waivers.pdfFile04/02/2026
Download fileDHHS Freedom of Choice Form for ICFs.pdfFile04/02/2026
Download fileDHHS Medically Complex Services Application for ICFs.pdfFile04/02/2026
Download fileDHHS Retroactive Authorization Request Form for Nursing Facilities and ICFs.pdfFile04/07/2026
Download fileDHHS Specialized Rehabilitative Services Application for Nursing Facilities.pdfFile04/02/2026
Download fileDentalAgreement.pdfFile03/31/2026
Download fileDonorMilkForm1-15.pdfFile02/25/2025
Download fileDoula Provider Attestation_3.2026.pdfFile03/03/2026
Download fileGenetic Testing Additional Info.pdfFile03/24/2026
Download fileHearingRequest2023.pdfFile02/25/2025
Download fileHearingRequestSpanish2019.pdfFile02/25/2025
Download fileHysterectomyAcknowledgment_Fillable.pdfFile02/25/2025
Download fileIOTN form instructions (Sept. 2025).pdfFile03/31/2026
Download fileModification Request Form_Fillable.pdfFile03/18/2026
Download fileOut_of_StateTravel3-26.pdfFile03/13/2026
Download filePPC_Doc_Submission_Form2-26.pdfFile03/13/2026
Download filePaymentAdjustment7-24.pdfFile02/25/2025
Download filePrivateDutyNursingGrid 03-26.xlsxFile03/31/2026
Download fileProvider User Access Agreement V4.pdfFile02/25/2025
Download fileProviderAgreement.pdfFile02/25/2025
Download fileRemittanceAdviceRequest11-21.pdfFile02/25/2025
Download fileTimelyFiling_Doc_Submission_Form.pdfFile04/07/2026
Download fileUrine Drug Testing Info.pdfFile03/31/2026
Download fileWheelchair Final Eval Form (ADA Compliant_Fillable).pdfFile03/24/2026
Download fileWheelchair Initial Evaluation Form (ADA Compliant- Fillable).pdfFile03/31/2026
Download fileWheelchairChecklist (ADA compliant_fillable).pdfFile03/31/2026
Download fileeMIPP_Coversheet.pdfFile02/25/2025