Get Request For Services At The Usdc

This guide provides clear instructions for filling out the REQUEST FOR SERVICES form at the Utah State Developmental Center. By following these steps, users can ensure they accurately complete the form to facilitate their request for services.

Follow the steps to successfully complete the form.

1. Press the ‘Get Form’ button to obtain the form and open it in the specified editor.
2. Begin by filling in the service(s) requested. Clearly specify the type of services you are seeking, such as neurology, psychiatric, adaptive wheelchair, or programmatic assistance.
3. Enter the name, date of birth, social security number, telephone number, and address of the individual for whom services are requested.
4. Indicate whether the individual is currently receiving services from the Division of Services for People with Disabilities by selecting 'Yes' or 'No.' If 'Yes,' please specify the type of service received.
5. Provide insurance information including the name of insurance companies, policy holder details, and relevant identification numbers for Medicaid or Medicare.
6. Identify who will be responsible for payments for services not covered by insurance, and complete the billing address and contact information.
7. If the person requesting services is different from the individual receiving them, fill out their name, title, address, telephone number, and relationship to the patient.
8. Indicate the best time to contact you, and provide additional contact information for support coordinators or other relevant individuals.
9. List any private providers previously contacted for the requested services, along with their names, addresses, and telephone numbers.
10. Provide a reason for any denied services experienced with private providers.
11. Ensure all required authorized signatures are included prior to service delivery, including the region director or nursing home administrator, developmental center medical services director, and others as needed.
12. Review the form for accuracy and completeness before submitting. Once complete, you can save changes, download, print, or share the form.

Complete your REQUEST FOR SERVICES form online today to ensure a smooth process.