Staff Forms

• 0-1 DSPD Employee Access Request Form opens in a new tab
• 0-2 USTEPS Support Coordinator Contracted Provider Access Request Form opens in a new tab
• 0-3 USTEPS & UPI User Email Change Request Form opens in a new tab
• 0-4 Non-DSPD State of Utah Employee Access Request Form opens in a new tab
• 0-5 Private Support Coordinator Company Access Request Form opens in a new tab
• 0-8 USTEPS Provider Interface (UPI) Individual User 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 Contracted Provider Email Change Request Form opens in a new tab
• 0-13 DSPD USTEPS Access Form - UCANS User Roleopens in a new tab
• 1-2 Authorization to Furnish Information and Release from Liability opens in a new tab
• 1-6 Invitation to Submit Offer to Provide Services (PDF) opens in a new tab
• 1-6 Invitation to Submit Offer to Provide Services (Word Version) opens in a new tab
• 1-8 Incident Report Form opens in a new tab
• 1-18 Request to Amend or Add to Record opens in a new tab
• 1-19 Evaluation for ESMC Waiting List One-Time Funded Services opens in a new tab
• 2-1G Graduated Fee Assessment opens in a new tab
• 2.9-SA Acquired Brain Injury Waiver Self-Administered Services Agreement opens in a new tab
• 2.9-SA Community Supports Waiver Self-Administered Services Agreement opens in a new tab
• 2.9-SA Limited Supports Waiver Self-Administered Services Agreement opens in a new tab
• 2.9-SA Physical Disabilities Waiver Self-Administered Services Agreement opens in a new tab
• 2.9-EA Acquired Brain Injury Waiver Self-Administered Services Employment Agreement opens in a new tab
• 2.9-EA Community Supports Waiver Self-Administered Services Employment Agreement opens in a new tab
• 2.9-EA Limited Supports Waiver Self-Administered Services Employment Agreement opens in a new tab
• 2.9-EA 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
• 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
• 3-4 Authorization to Disclose Protected Health Information opens in a new tab
• 5-2 Deceased Client Report Form opens in a new tab
• 5-3 Code of Conduct Certification 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
• 201 Supported Work Independence Client Information Form opens in a new tab
• 202 Supported Work Independence Participation Agreement opens in a new tab
• 203 Community Services Brokering Action Plan opens in a new tab
• 301 Telecommuting Agreement Form opens in a new tab
• 302 Telecommuting Feasibility Worksheet opens in a new tab
• 303 Home Office Feasibility Worksheet opens in a new tab
• 304 Home Office Agreement Form opens in a new tab
• 305 Cell Phone Agreement Form opens in a new tab
• 801 PASRR Categorical Determination opens in a new tab
• 802 PASRR Individualized Determination 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
• 902 Physical Examination Report opens in a new tab
• 928 Exceptional Needs Prior Authorization for Residential Habilitation 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 3.0 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
• DPF-2 Medicaid Special Circumstance Involuntary Disenrollment Notice of Intent opens in a new tab
• DPF-3 DHCF Decision Notice for Special Circumstance Involuntary Disenrollment 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:

• DHS Employee Portal- Forms opens in a new tab

• 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 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