Follow the steps to successfully complete the application.

1. Press the ‘Get Form’ button to obtain the application and open it in the provided editor.
2. Begin by entering the child's name in the designated field, including their last name, first name, and middle initial.
3. Next, fill in the date of birth and indicate the child's gender, choosing from options of 'male' or 'female'.
4. Complete the parent or guardian's name section, providing last name, first name, and middle initial.
5. Provide the home address, including street address, apartment or unit number (if applicable), city, state, ZIP code, as well as the home and alternate phone numbers.
6. Add the email address for future correspondence regarding the application.
7. In the 'Medical Intervention, Consultation and Conditions' section, indicate the primary medical provider for the child and the frequency of visits.
8. List all specialty physicians and healthcare providers the child has seen in the past year, along with their specialties, the conditions treated, and the date of the last visit.
9. Indicate any medical devices, therapies, or service needs, specifying prolonged dependence on medical devices or treatments.
10. Provide information on any prescribed medications, including the name and schedule for each.
11. Detail any functional or developmental limitations and the child’s mobility description, selecting from the provided options.
12. Complete the self-care assessment, marking the child's abilities in age-appropriate tasks.
13. Answer the caregiver impact questions that address how the child's condition has influenced family health and financial status.
14. If applicable, indicate if you are applying for multiple children and include their names.
15. Select the annual out-of-pocket medical expenses and check all applicable employment impact items for parents or guardians.
16. If your child has medical insurance, confirm this and list out the providers in the designated section.
17. Finally, review the entire application for accuracy, confirm the accuracy of the provided information, add the date and your signature before submitting the application.

Begin completing the UT DoH Medically Complex Children's Waiver Application online today to ensure your child's eligibility for necessary services.