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 file.pdfFile02/25/2025
Download file2021-04-05_Utah_Medicaid_Initial_Wheelchair_Evaluation_Form.docxFile02/25/2025
Download file2021-04-05_Utah_Medicaid_Initial_Wheelchair_Evaluation_Form.pdfFile02/25/2025
Download file2023-07 Medical Review Form - Out of State Travel Request.pdfFile02/25/2025
Download fileAbortion Acknowledgement Form.pdfFile02/25/2025
Download fileAgreementFinancial.pdfFile02/25/2025
Download fileBehaviorally complex application.pdfFile02/25/2025
Download fileCONSENTIMIENTO PARA LA ESTERILIZACIÓN.pdfFile02/25/2025
Download fileCombiningAdmission.pdfFile02/25/2025
Download fileConsent for Sterilization_ Form HHS-687.pdfFile02/25/2025
Download fileDME Repair_Replacement Info.pdfFile02/25/2025
Download fileDentalAgreement.pdfFile02/25/2025
Download fileDonorMilkForm1-15.pdfFile02/25/2025
Download fileFreedom of Choice Acknowledgement.pdfFile02/25/2025
Download fileGenMedForm.pdfFile02/25/2025
Download fileGenetic Testing Additional Info.pdfFile02/25/2025
Download fileHearingRequest2023.pdfFile02/25/2025
Download fileHearingRequestSpanish2019.pdfFile02/25/2025
Download fileHomehealth60day.pdfFile02/25/2025
Download fileHysterectomyAcknowledgment_Fillable.pdfFile02/25/2025
Download fileMedicaid Final Wheelchair Evalaution Form.pdfFile02/25/2025
Download fileMedically complex services application.pdfFile02/25/2025
Download fileModification Request Form.pdfFile02/25/2025
Download filePPC_Doc_Submission_Form4-23.pdfFile02/25/2025
Download filePRISM-SEC-AGRMNT.pdfFile02/25/2025
Download filePT_OTRehabAgreement.pdfFile02/25/2025
Download filePaymentAdjustment7-24.pdfFile02/25/2025
Download filePersonalCareCapitated1-12.pdfFile02/25/2025
Download filePrivateDutyNursingGrid.pdfFile02/25/2025
Download filePrivateDutyNursingGrid.xlsxFile02/25/2025
Download fileProvider User Access Agreement V4.pdfFile02/25/2025
Download fileProviderAgreement.pdfFile02/25/2025
Download fileRadiationDosimetryForm4-14.pdfFile02/25/2025
Download fileRemittanceAdviceRequest11-21.pdfFile02/25/2025
Download fileRetroactive authorization request form.pdfFile02/25/2025
Download fileSkilledNurseForm1-10.pdfFile02/25/2025
Download fileSpecialized rehabilitative services application.pdfFile02/25/2025
Download fileTAM SUD Verification Form - Dental.pdfFile02/25/2025
Download fileTimelyFiling_Doc_Submission_Form4-23.pdfFile02/25/2025
Download fileUrine Drug Testing Info.pdfFile02/25/2025
Download fileWarrantRequest1-22.pdfFile02/25/2025
Download fileWheelchairChecklist10-19.pdfFile02/25/2025
Download fileWheelchairForm1-20.pdfFile02/25/2025
Download fileeMIPP_Coversheet.pdfFile02/25/2025
Download fileeMIPP_Coversheet_09152016.pdfFile02/25/2025