Forms
For Staff, Families, SCEs, and Providers
Caregiver Compensation Forms (Coming Soon!)
Self-Administered Services Forms
- 2-9SA Acquired Brain Injury Waiver Self-Administered Services Agreement opens in a new tab
- 2-9SA Community Supports Waiver Self-Administered Services Agreement opens in a new tab
- 2-9SA Limited Supports Waiver Self-Administered Services Agreement opens in a new tab
- 2-9SA Physical Disabilities Waiver Self-Administered Services Agreement opens in a new tab
- 2-9EA Acquired Brain Injury Waiver Self-Administered Services Employment Agreement opens in a new tab
- 2-9EA Community Supports Waiver Self-Administered Services Employment Agreement opens in a new tab
- 2-9EA Limited Supports Waiver Self-Administered Services Employment Agreement opens in a new tab
- 2-9EA Physical Disabilities Waiver Self-Administered Services Employment Agreement opens in a new tab
- 2-9C Acquired Brain Injury Application for Certification opens in a new tab
- 2-9C Community Supports Waiver Application for Certification opens in a new tab
- 2-9C Limited Supports Waiver Application for Certification opens in a new tab
- 2-9C Physical Disabilities Waiver Application for Certification opens in a new tab
- 2.9-OT Overtime Increase Request opens in a new tab
- 2.9-T Notice of Termination of FMS Services opens in a new tab
- Background Check Application Instructions opens in a new tab
- Self-Administered Services Review Checklist opens in a new tab
- 5-3 DSPD Code of Conduct Certification opens in a new tab
- 5-3 Certificación de Código de Conducta opens in a new tab
- Support Strategies opens in a new tab
- Monthly Summary opens in a new tab
- Service Specific Training opens in a new tab
USTEPS and UPI Access Forms
- 0-1 DSPD Employee USTEPS Access Form opens in a new tab
- 0-2-DHHS-Private-Support-Coordiantor-USTEPS-Access-Formopens in a new tab
- 0-3 Email Change Request Form opens in a new tab
- 0-4 Non DSPD State of Utah Employee USTEPS Access Request Form opens in a new tab
- 0-5 Private Support Coordinator Company Access Request Form opens in a new tab
- 0-8 UPI Access Form opens in a new tab
- 0-9 USTEPS Provider Interface (UPI) Provider Company Designee Access Form opens in a new tab
- 0-10 Provider Company Email Change Request Form opens in a new tab
- 0-13 USTEPS Support Coordinator Contracted Provider Access Request Form - UCANS
Other Forms for SCEs and Providers
- 1-2 Authorization to Furnish Information and Release from Liability opens in a new tab
- 295 CAPS Form – One-Time Payment Form opens in a new tab
- 928 Exceptional Needs Prior Authorization for Residential Habilitation opens in a new tab
- Employee Medicaid Disclosure opens in a new tab
- DSPD Civil Commitment Referral opens in a new tab
Other General Forms (DSPD)
- 2-1G Graduated Fee Assessment opens in a new tab
- 3-1 Application for Physical Disabilities Services opens in a new tab
- 3-2 Critical Needs Assessment for Physical Disabilities Services opens in a new tab
- 3-3 PDW Parents as Providers opens in a new tab
- 18 Request for ICD-10 Code From A Diagnosing Professional opens in a new tab
- 19C Eligibility for ID-RC Services opens in a new tab
- 305 Cell Phone Agreement Form opens in a new tab
- 818 Choice of Service System CSW Waiver opens in a new tab
- 818 Choice of Service System CSW Waiver (Spanish) opens in a new tab
- 818B Choice of Service System ABI Waiver opens in a new tab
- 818C Choice of Service System LSW Waiver opens in a new tab
- 824L Social History opens in a new tab
- 843B Case Transfer Information opens in a new tab
- 929 Respite – Intensive Screening opens in a new tab
- 930 Enhanced Supervision & Rate Form opens in a new tab
- 931 SIS Risk Section 4 opens in a new tab
- Comprehensive Brain Injury Assessment (CBIA) Version 3.1 opens in a new tab
- Comprehensive Brain Injury Assessment Score Cards opens in a new tab
- Comprehensive Brain Injury Assessment Handouts opens in a new tab
- Covid-19 Caregiver Compensation Authorization Form C19 opens in a new tab
- GRAMA Request for Records opens in a new tab
Regardless of the model of delivery (Provider or SAS) all background screening applicants are now being submitted using one standardized application. The application for background screening can be accessed by following the link below:
- HIPAA - Notice of Privacy Practices opens in a new tab
- HIPAA - Information Request Form opens in a new tab
- HIPAA - Request for Restricted Use and Disclosure opens in a new tab
- HIPAA - Request for Accounting Disclosure opens in a new tab
- HIPAA - Request for Amendment of Health Records opens in a new tab
- HIPAA - Authorization to Disclose Protected Health Information opens in a new tab