Utah Medicaid Forms
The forms below are updated on a quarterly basis when necessary. They have been alphabetized for your convenience. If you have questions, contact the webmaster
If you are a Medicaid member, you can access literature, forms, and other publications at the Utah Medical Benefits website; click here
Forms
Select Below 10A Preadmission, Inpatient Abortion Acknowledgement Abortion Prohib Payment R414-1B Agreement of Financial Responsibility Consent for Combining Admission Form Dental Agreement Direct Deposit/EFT Disclosure (Client Request) Disclosure (From Division) Disclosure (To Division) Documentation Submission Form Donor Milk Form Emergency Services (Non-Citizens) Documentation Submission Form eMIPP Coversheet General Medical Form Hearing Request Hearing Request (Español) Hospice Prior Authorization Request Form Hospice Post-Authorization for Service Intensity Add-On (SIA) Hospice Independent Physician Review for Extended Care Hysterectomy Acknowledgment Form Hysteroscopic Tubal Occlusive Device Checklist Nursing Facility Contract & Agreement Out of State Travel Form Outlier PPC Medical Record Doc Submission PA (Prior Authorization) Request Payment Adjustment Request Payment Adjustment Request for Pharmacy PRISM Access Agreement Private Duty Nursing Acuity Grid Private Duty Nursing Acuity Grid (Printable) Provider Agreement Provider User Access Agreement PT OT Rehab Agreement Remittance Advice Request Form Sterilization Consent Sterilization Consent (Spanish) Warrant & Publication Request Form Wheelchair Initial Evaluation Form Wheelchair Initial Evaluation Form (Printable) Wheelchair Final Evaluation Form Wheelchair Training Checklist (Power Wheelchair)
