Utah Department of Health and Human Services Forms

This form is used for foster parents in Utah to report their private vehicle usage.

This form is used for requesting the sealing of an allegation in Utah.

This form is used for obtaining financial assistance for children with special health care needs in Utah.

This document is an application form for the Children's Hearing Aid Program (CHAP) in Utah. It is used by participants to apply for hearing aids for children.

This type of document is used for refusing a CCHD (Congenital Heart Disease) screening in Utah. It allows individuals to decline participation in the screening program.

This document is used to refer parents and infants to a program in Utah that provides support and resources for early childhood development.

This document is a referral for individuals in Utah to undergo a diagnostic audiological evaluation, which helps assess hearing loss and related issues.

This form is used for declining CMV testing in the state of Utah.

This form is used for granting authorization to disclose health information to other providers in the state of Utah.

This Form is used for referring patients to care coordination services in Utah. It helps facilitate communication and collaboration among healthcare providers to ensure patients receive appropriate and timely care.

This document is used to authorize the disclosure of health information to Health Clinics of Utah in the state of Utah.

This document is a consent form for telehealth services in the state of Utah. It also includes information about the notice of privacy practices and a financial agreement.

This form is used for giving permission to access and share medical records in Utah.

This document provides information about how your personal health information is protected and used by Family Dental Plan (FDP) and Health Clinics of Utah (HCU) in Utah. It explains your rights regarding your health information and how it may be shared.

This form is used for gathering medical information for individuals living in Utah. It helps healthcare providers assess a person's health status and make appropriate treatment decisions.

This document is used for obtaining consent for tele-intervention services in the state of Utah.

This Form is used for reporting health visit information in the state of Utah.

This form is used for determining the fees for family-related services in Utah.

This document is used for determining the family fee in Utah.

This document is used for conducting health, hearing, and vision assessments in the state of Utah. It helps to evaluate an individual's overall health and assess their hearing and vision capabilities.

This document outlines an individualized plan for credentialing caregivers and ensuring the safety of infants in Utah.

This self-assessment form is used by early intervention providers in Utah to evaluate their own level of competence. It helps them identify areas of strength and areas that may need improvement in their work with children and families.

This document is used for observing and demonstrating the progress and development of individuals with disabilities in Utah, as part of the Individualized Family Service Plan (IFSP) process.

This document is a checklist of family-centered practices and the Individualized Family Service Plan (IFSP) used in Utah. It outlines the steps and considerations involved in creating a plan for early intervention services for children with developmental delays or disabilities.

This document is used for the evaluation and observation of eligibility for certain benefits or programs in the state of Utah.

This document is a set of testing orders for Cytomegalovirus (CMV) and Auditory Brainstem Response (ABR) testing in the state of Utah. It is used to request these specific medical tests for individuals.

This document provides the results of the newborn hearing screening and critical congenital heart disease (CCHD) screening in the state of Utah. It helps identify any hearing loss or potential heart problems in newborns.

This document is a checklist specifically designed for families in Utah to assess their telehealth technology and ensure they have the necessary tools to access telehealth services.

This form is used for reporting the results of newborn hearing screenings and congenital heart disease screenings on a weekly basis in Utah.

This form is used for requesting information from the Child Abuse Registry in Utah. It allows individuals or organizations to request information about an individual's history of child abuse allegations or convictions.

This type of document is a form for requesting an administrative hearing in Utah. It is used to submit a formal request to address a specific issue with the Utah Department of Child and Family Services.

This form is used for authorizing the release of information about a child or family maintained by the Division of Child and Family Services in Utah to a third party.

This Form is used for requesting Department of Child and Family Services (DCFS) records in Utah under the Government Records Access and Management Act (GRAMA).