Children With Special Health Care NeedsPhone:(801)584-8284 Toll Free:(800)829-8200

Forms

CSHCN Forms at a glance:

Release of Information

Children's Hearing Aid Program (CHAP) and Hearing Aid Recycling Program (HARP)

Critical Congenital Heart Defect (CCHD) Project

Cytomegalovirus (CMV) Public Health Initiative

Early Hearing Detection and Intervention

Fostering Healthy Children Program

Health Visit Report Form (HVR584)

This is the standard form for all health visits and is to be completed by your health care provider and then returned (within 3 days) to the Fostering Healthy Children Program.

Integrated Services Program

Kurt Oscarson Children's Organ Transplant Fund

Newborn Bloodspot (Heelstick) Screening

2-part Kit Private Purchase Order Form

In order to serve our Utah population more effectively the Newborn Bloodsopt (Heelstick) Screening Program is happy to announce 2-part kit cards may now be ordered individually and privately.


Destruction of Dried Blood Spot Form | Spanish

To destroy your child’s blood spot sample after the newborn bloodspot (heelstick) screen testing and when all necessary diagnostic testing has been completed, you may request the destruction of the blood spot sample.


Religious Objection Form | Spanish

In cases where parents object on the grounds they are members of a specified, well-recognized religious organization whose teachings are contrary to the tests required complete and submit this form.

Utah Birth Defect Network

Champion Reporting Form

The champion reporting form is used by physicians, nurses, or midwives in birthing facilities to report any infant born with a diagnosed or suspected birth defect

 

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