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Bureau of Financial Services


FCP and FRV Forms

For questions, contact
David Meadows (801-538-6790)
Email: 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 Bureau of Financial Services. 

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

Please use the 2016 Forms. Old forms/spreadsheets will be returned.

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:

ICF/ID Nursing Homes:

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 the first business day in March at 6:00 pm.  Failure to do so will preclude the data from being used in the July 1st 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).

If you need an earlier version of Excel, please contact David Meadows.

Via U.S. Mail
Utah Department of Health
Attn: David Meadows
PO Box 143104
Salt Lake City, UT 84114-3104
Via UPS or FedEx
Utah Department of Health
Attn: David Meadows
288 North 1460 West
Salt Lake City, UT 84116

Last Updated July 21, 2014