USHAI 100P State Hospital Referral Information – Adult Patient and Private Insurance

01/03 Revised 03/13/03


It is the responsibility of the Utah State Hospital (USH) to send ORS the required information to open a case.  The appropriate cases will be opened on ORSIS once all the necessary information is received from the USH.  


USH Referral Forms


The USH should complete and send the following referral forms, when applicable, to team 78 after a patient is admitted. 


1.         Face Sheet Referral:  This USH referral identifies the patient and the patient’s spouse (if married), social security number, date of birth, date of admission to the USH, and home address.  This form may also include whether the patient has known assets, income, or insurance coverage, etc.  ORS should receive this completed form from the USH on all patients, except forensic patients.


2.         Utah State Hospital Patient Insurance Information (form SHII):  This USH form includes the patient’s detailed primary and secondary insurance information.  ORS should receive this completed form from the USH when a patient has medical insurance.


3.         Authorization for Utah State Hospital to Release Medical Records:  This release form must be signed by the patient, parent, guardian, or agent in order for ORS to have the authority to bill the patient’s insurance company.  This form should accompany the “Utah State Hospital Patient Insurance Information” form.