Bureau of Financial Services

FCP and FRV Forms

For questions, contact
David Meadows (801-538-6790)
DMeadows@Utah.Gov

Facility Cost Profile (FCP) Forms

These forms are provided for the convenience of nursing home providers in assisting them in their reporting requirements.  Questions should be directed to David Meadows of the Office of Internal Audit. 
 

If you are unsure about an issue, please ask questions.

Click cover letter, instructions or forms below.  When prompted select "save" and then navigate to where on your local drive you want to save the file.

Please read the instructions in their entirety before completing the FCP forms.  Also, please be sure to carefully review your FCP before submission.

NF Nursing Homes:

• Cover Letter FY12 (PDF Document)
• Instructions FY12 (Word Document)
• Forms FY12 (Excel Spreadsheet)

ICF/MR Nursing Homes:

• Cover Letter FY12 (PDF Document)
• Instructions FY12 (Word Document)
• Forms FY12 (Excel Spreadsheet)

Related-Party Audit Disclosure - This form is to provide greater understanding of what constitutes related-party compensation and related-party transactions.  This form will help assure a common understanding of related-party issues.  The end result being that all related-party compensation/transactions will be properly disclosed in accordance with CMS Pub 15-1.

FRV Data Report Forms

Reminder: This report is optional.  If submitted, it must be received no later than March 1, 2013 at 6:00 pm.  Failure to do so will preclude the data from being used in the July 1, 2013 FRV calculation.  (No extensions will be granted.)

Please be sure to carefully read and follow the instructions.

Questions should be directed to David Meadows (contact information is on the top of this page).

• 2013 Cover Letter (Word Document)
• 2013 Instructions (Word Document)
• 2013 Forms (Excel Spreadsheet)

Via U.S. Mail Utah Department of Health DHCF, BFS Attn: David Meadows PO Box 143104 Salt Lake City, UT 84114-3104

Via UPS or FedEx Utah Department of Health DHCF, BFS Attn: David Meadows 288 North 1460 West Salt Lake City, UT 84116