Safety Exit

35th Annual Crime Victims Conference April 27-28, 2023

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Utah Office
for Victims of Crime

  • File A Claim
  • Victims’ Financial Assistance
  • Victims’ Rights & Resources
  • Grants
  • Training
  • About Us
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Utah Office
for Victims of Crime

  • General Billing and Payment Information
  • Medical Service Providers
  • Mental Health Service Providers
    • Mental Health Provider Forms
    • Mental Health Treatments for Adolescent/Adult Victims of Sexual Assault
  • Dental Service Providers
  • Code R Service Providers
  • Provider Forms

Reparations Provider Forms

Mental Health Treatment Plans

Mental Health Treatment Plan for Adults (.pdf)

Mental Health Treatment Plan for Adults (.docx)

Mental Health Treatment Plan for Minors (.pdf)

Mental Health Treatment Plan for Minors (.docx)

Mental Health Provider Statement (.pdf)

Mental Health Provider Statement (.docx)

 

Common Billing Forms

CMS-1500 Billing Form

UB-04 Billing Form

ADA Dental Claim Form

Fast Track Reimbursement Form - Code R

W9 (UOVC Just needs the first page complete)

Address

Utah Office for Victims of Crime (UOVC)
350 East 500 South Suite 200
Salt Lake City, Utah 84111

Agency Hours: 8am - 5pm, M-F

Phone

General Assistance
801-238-2360

Toll-Free
800-621-7444

Message

Email: crimevictims@utah.gov
Fax: 801-533-4127

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  • File A Claim
  • Victims’ Financial Assistance
  • Victims’ Rights & Resources
  • Grants
  • Training
  • About Us