Utah State Government Forms

Form Title	Agency	Topics
113b Summary of Medical Record – Occupational Exposure	Anti-Discrimination
1-2 Authorization to Furnish Information and Release from Liability	Health Facility Licensure
1-2 Authorization to Furnish Information and Release from Liability	HIV/AIDS/TB Control, Bureau
1-2 Authorization to Furnish Information and Release from Liability	Services for People with Disabilities
1391 Instructions	Department of Transportation	Construction, Appendix / Toolbox, Appendix / Toolbox
1444 Instructions	Department of Transportation	Construction, Appendix / Toolbox, Appendix / Toolbox
152 Appointment of Counsel	Department of Labor Commission
152 Appointment of Counsel	Anti-Discrimination
152 Appointment of Counsel	Occupational Safety & Health
1-6 Invitation to Submit Offer to Provide Services	Health Facility Licensure
1-6 Invitation to Submit Offer to Provide Services	HIV/AIDS/TB Control, Bureau
1-6 Invitation to Submit Offer to Provide Services	Services for People with Disabilities
18 Request for ICD-10 Code From A Diagnosing Professional	Services for People with Disabilities
18 Request for ICD-10 Code From A Diagnosing Professional	Health Facility Licensure
18 Request for ICD-10 Code From A Diagnosing Professional	HIV/AIDS/TB Control, Bureau
19C Eligibility for ID-RC Services	Health Facility Licensure
19C Eligibility for ID-RC Services	Services for People with Disabilities
19C Eligibility for ID-RC Services	HIV/AIDS/TB Control, Bureau
2018 Medical Fee Standards	Department of Labor Commission
2018 Workers’ Compensation Quick Reference Guide	Department of Labor Commission