Medicaid Enrollee Resources | Bear River Mental Health

Medicaid Member Handbook
Medicaid Member Handbook- Spanish

Advance Directives

https://le.utah.gov/xcode/Title62A/Chapter15/62A-15-S1004.html

English Forms

Authorization for Release of Records and/or Request for Access
Revocation of Auth for Release of Records – Request for Access
Client Admission Form
Personal History Packet – Adult
Personal History Packet – Youth

Spanish Forms

Authorization for Release of Records and/or Request for Access
Revocation of Auth for Release of Records Spanish
Client Admission Form
Personal History Packet – Adult
Personal History Packet – Youth

If you are unable to access and print the forms electronically, you can request paper copies—free of charge. Request forms by calling one of our outpatient facilities and speaking to a friendly member of our support staff. Cache and Rich County facilities can be reached at (435) 752-0750; Brigham City (435) 734-9449; and the Tremonton area at (435) 257-2168. Please allow five business days for delivery.