Provider Setup
This form allows agencies to accept incoming referrals in UHMIS or update their information as needed.

It should be filled out by an agency security officer or by organizational leadership.

Only the questions marked as required are required by HMIS to set up a referral provider in the system, all other questions are optional.

Please contact the HMIS Lead Agency if you have any questions.

Thank you,
UHMIS Lead Agency Team
HMIS@utah.gov
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1. Agency Contact
This first section gives the UHMIS Lead Agency a contact person if we have questions or concerns about the form. It is not entered into HMIS unless identified later in the form.
Name of contact *
Email *
Phone Number *
2. Provider Setup
Enter a Provider Name and the street address where the provider is located. This information will be useful in contacting the provider and referring clients.
Provider Name *
Provider Type *
Address (Street)
Address 2 (Suite #)
City *
State *
Zip *
Phone
This number should be the one clients can use to contact the agency.                                                                                                              Please include the area code.
Website Address
3. Accessing Organizations
Are there any organizations the Agency would like to restrict referrals from? *
By default, all HMIS accessing organizations are selected, meaning the agency could receive a referral from anywhere in the state.                                                                                                                                                                                                             The agency may request this to be limited to suit its business purposes. For example, it may not want to receive referrals from outside its LHCC, or from a specific provider type (such as Domestic Violence Service Providers).
4. Mailing Address
Enter a mailing address if it is different from the street address
Mailing Address
Mailing Address 2 (Suite #)
Mailing City
Mailing State
Clear selection
Mailing Zip
5. Time Available
Enter the hours this provider is available each day and also the days they are available.
Hours Available
Days Available
6. Other Information
Message To Referrals
This a message referring providers and clients will see when they receive the referral.
National Provider Identifier
A national provider identifier (NPI) is a standard identifier mandated by the Health Insurance Portability and Accountability Act of 1996 (HIPPA), if unsure please refer to npiregistry.cms.hhs.gov
Languages
Intake Description
Fees Description
Eligibility Description
ADA Description
Funding Description
Owning Organization
If nothing is selected, this will be defaulted to the same organization identified in the first question 'Provider Name.'
7. Referral Contact
Identify the contact information for the Provider below. The contact information will be used to contact the provider when a referral is made.
Referral Contact (Name/Group)
For Example: John Smith or Intake Office
Referral E-Mail
This email will get an automatic notification from HMIS when a referral is created (if selected by the user)
Referral Contact Phone
This number may be provided to the referred client or person entering the referral
Telephone 2
Secondary telephone number if needed.
8. Services
Please provide a few times you are available to discuss the services that your agency would like to receive referrals for. *
We will need to review the services the agency currently has access to, and determine which ones should be referable to your agency. We can also discuss setting up new service if all of your needs are not met with the current list of available services.
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