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Utah Autism Waiver Application
Please enter the required information for the recipient below. Once completed, click the "Submit Application" button to save and submit the data.
* denotes required field
Child's First Name:
Child's Middle Name:
Child's Last Name:
Child's Date of Birth:
* Please note - in order to be elegible to recieve services, the child's date of birth must be between May 1, 2008 and December 31, 2012 *
County of Residence:
Parent/Guardian Name (1):
Parent/Guardian Name (2):
Alternative Telephone Number:
Are you submitting applications for more than one child? If so, please provide their names and dates of birth.
Does your child have an autism spectrum diagnosis (ASD) from a clinical professional, licensed to give a diagnosis?
* Please note - if your child is selected to participate, you will need to provide supporting documentation within 10 days of the request. Examples of supporting documentation include: a copy of the doctor's notes, assessment results or other reports that verify the ASD diagnosis. *
Does your child have assets in their name (bank accounts, trust fund, etc.) and is the balance more than $2000 at the start of each calendar month? Only the child's assets are considered for eligibility in this program.
If my child is selected through this randomized process, I understand that I will be required to apply for Medicaid benefits with the Department of Workforce Services. All factors of eligibility must be met in order to be considered for the Medicaid Autism Waiver.