Forms and documents
The documents, forms, and checklists listed on this page are made available to assist providers with maintaining compliance. Some of the documents here are mandatory while others are offered as a reference.
Health facilities program forms
OLST – Order for Life-Sustaining Treatment
- Life with Dignity (OLST) – (English)
- Life with Dignity (OLST) – (Spanish)
- OLST Conversation Guid
For more information regarding OLST and Advance Directives, see the Utah Commission on Aging website.
Core competency tools for assisted living providers:
Facility Reported Incidents for Nursing Homes ONLY (Medicare and/or Medicaid certified):
- DLBC – HS Form 358: Facility Reported Incident Initial Report
- DLBC – HS Form 359: Follow-Up Investigation Report
Facility Reported Incidents for ALL Non-Nursing Home Providers (ALF, ICF/IID, HH, Hospice, ESRD, etc…)
- Please submit incident reports through your licensing provider portal at ccl.utah.gov
- For instructions on using your provider portal and submitting critical incidents, please review our DLBC provider portal tour
- Information Sheet – Facility/Agency Licensing
- Fee Schedule - Fiscal Year 2025 (July 1, 2024 - June 30, 2025)
- Fee Schedule – Fiscal Year 2024 (July 1, 2023 – June 30, 2024)
- Fee Schedule – Fiscal Year 2023 (July 1, 2022 – June 30, 2023)
- Notice of Intent
- Satellite Notice of Intent
- Mammography Application
- Rural Healthcare Clinic Initial Requirements
- Health Facility Request for Agency Action/License
New Provider Orientation Schedule — Reach out via email to: [email protected]