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Get UT DWS-ESD 354 2015-2024

1 SLC, UT 84131-9988 D26515001200105 Disability Medicaid Team Phone #: Ph: (801) 245-4848 Toll # 1-877-824-6531 Fax: (801) 526-9339 Medicaid ID or PID ________________________________________ Case # _________________________________________________ The following sections need to be completed in detail by the applicant or applicant’s representative. Please use a black pen to complete the form. Return the completed form within 10 days to your local DWS office or mail/fax to the address/fax .

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