Bureau of Licensing and Certification, Utah Department of Health 2026

1. Click ‘Get Form’ to open the Bureau of Licensing and Certification document in the editor.
2. Begin by entering the patient's last name, first name, middle initial, date of birth, and last four digits of their Social Security number in the designated fields.
3. Fill in the effective date of the order and the patient's address including street, city, state, and zip code.
4. Provide the medical provider's name and phone number. Ensure this information is accurate for future communications.
5. In Section A, select one option regarding cardiopulmonary resuscitation (CPR) based on patient preferences. Make sure to check only one box.
6. Proceed to Section B to choose medical interventions. Again, select only one option that aligns with the patient's wishes.
7. Complete Section C regarding artificial nutrition by selecting an appropriate option based on patient preferences.
8. Ensure all required signatures are obtained from both the medical provider and patient or surrogate decision-maker before finalizing the form.

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