Personal Care Division of Medicaid and Health Financing and C - health utah 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the 'Date of Request' at the top of the form. This is essential for tracking your submission.
3. Fill in the 'Patient Name' section with the last name, first name, and middle initial of the patient.
4. Provide the 'Date of Birth', 'Age', and 'Sex' by selecting either Male or Female.
5. Enter the 'Medicaid ID #' for accurate identification within the system.
6. List the requested medical supply, therapy, imaging, or procedure in section 6, ensuring to prioritize the primary procedure.
7. Include relevant CPT codes or surgical codes in section 7 along with the number of units requested in section 8.
8. In section 14, summarize the patient's medical history and attach any necessary supporting documentation to justify your request.
9. Complete sections 15 and 16 with details about both requesting and referring providers, including names, addresses, phone numbers, and NPI numbers.

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