STAFF FORMS
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- 0-1 DSPD Employee Access Request Form
- 0-2 USTEPS Support Coordinator Contracted Provider Access Request Form
- 0-3 USTEPS & UPI User Email Change Request Form
- 0-4 Non-DSPD State of Utah Employee Access Request Form
- 0-5 Private Support Coordinator Company Access Request Form
- 0-6 State of Utah Employee Read Only Access Form
- 0-7 State of Utah Employee No Role Access Request Form
- 0-8 USTEPS Provider Interface (UPI) Individual User Access Form
- 0-9 USTEPS Provider Interface (UPI) Provider Company Designee Access Form
- 0-10 Contracted Provider Email Change Request Form
- 0-11 Non-DSPD State of Utah Employee UPI Incident Report Management Access Request Form
- 1-2 Authorization to Furnish Information and Release from Liability
- 1-6 Invitation to Submit Offer to Provide Services (PDF)
- 1-6 Invitation to Submit Offer to Provide Services (Word Version)
- 1-8 Incident Report Form
- 1-18 Request to Amend or Add to Record
- 1-19 Evaluation for ESMC Waiting List One-Time Funded Services
- 2-1G Graduated Fee Assessment
- 2.9-SA Acquired Brain Injury Waiver Self-Administered Services Agreement
- 2.9-SA Community Supports Waiver Self-Administered Services Agreement
- 2.9-SA Limited Supports Waiver Self-Administered Services Agreement
- 2.9-SA Physical Disabilities Waiver Self-Administered Services Agreement
- 2.9-EA Acquired Brain Injury Waiver Self-Administered Services Employment Agreement
- 2.9-EA Community Supports Waiver Self-Administered Services Employment Agreement
- 2.9-EA Limited Supports Waiver Self-Administered Services Employment Agreement
- 2.9-EA Physical Disabilities Waiver Self-Administered Services Employment Agreement
- 2-9C Acquired Brain Injury Application for Certification
- 2-9C Community Supports Waiver Application for Certification
- 2-9C Limited Supports Waiver Application for Certification
- 2-9C Physical Disabilities Waiver Application for Certification
- 3-1 Application for Physical Disabilities Services
- 3-2 Critical Needs Assessment for Physical Disabilities Services
- 3-3 PDW Parents as Providers
- 3-4 Authorization to Disclose Protected Health Information
- 5-2 Deceased Client Report Form
- 5-3 Code of Conduct Certification
- 18 Request for ICD-10 Code From A Diagnosing Professional
- 19C Eligibility for ID-RC Services
- 201 Supported Work Independence Client Information Form
- 202 Supported Work Independence Participation Agreement
- 203 Community Services Brokering Action Plan
- 301 Telecommuting Agreement Form
- 302 Telecommuting Feasibility Worksheet
- 303 Home Office Feasibility Worksheet
- 304 Home Office Agreement Form
- 305 Cell Phone Agreement Form
- 801 PASRR Categorical Determination
- 802 PASRR Individualized Determination
- 818 Choice of Service System CSW Waiver
- 818 Choice of Service System CSW Waiver (Spanish)
- 818B Choice of Service System ABI Waiver
- 818C Choice of Service System LSW Waiver
- 824L Social History
- 843B Case Transfer Information
- 902 Physical Examination Report
- 928 Exceptional Needs Prior Authorization for Residential Habilitation
- 929 Respite – Intensive Screening
- 930 Enhanced Supervision & Rate Form
- 931 SIS Risk Section 4
- Comprehensive Brain Injury Assessment (CBIA) Version 3.0
- Comprehensive Brain Injury Assessment Score Cards
- Comprehensive Brain Injury Assessment Handouts
- Covid-19 Caregiver Compensation Authorization Form C19
- DPF-2 Medicaid Special Circumstance Involuntary Disenrollment Notice of Intent
- DPF-3 DHCF Decision Notice for Special Circumstance Involuntary Disenrollment
- GRAMA Request for Records