If you need help filling out this form, call us at: (Si necesita ayuda para llenar o completar este formulario, llamenos al:)
Medicaid: 801-213-4104 / 1-833-981-0212
Commercial: 801-213-4111 / 1-833-981-0213
Individual: 801-213-4008 / 1-833-981-0214

If you are deaf or hard of hearing, you can call Utah Relay Services at 711 or 1-800-346-4128. Si habla español, puede llamar a Spanish Relay Utah al 1-888-346-3162. These are free public telephone relay services or TTY/TDD. Estos son servicios gratuitos de retransmisión telefónica pública o TTY / TDD.

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You can fax the information to the Complaint Team at the fax # 801-587-9985.

You may mail the information to:
Complaint Team
6053 Fashion Square Dr., Suite 110
Murray, UT 84107