Department of Workforce Services

PO BOX 143245
SALT LAKE CITY, UT 84114-3245

Date Mailed: 11-17-2016

Case Number: 7131026

PID: 020321289

RENEE ELISAMA VASQUEZ

756 S 360 E
# 225
SALT LAKE CITY, UT 84111
Disability Medicaid Addendum Packet
Dear RENEE ELISAMA VASQUEZ
We have received your application for Disability Medicaid. The State Medical Disability Office will determine if
you are disabled.
We need the enclosed forms completed and returned.

Medicaid Disability Addendum (Form 354) - Check your personal information for accuracy. Include
your medical provider/facility/hospital name, address, phone number and fax number on the form.
Customer Authorization to Disclose Health Information (Form 114R) - If you have more than one
medical provider, make copies and complete a separate form for each medical provider.

Please return these forms as quickly as possible. Once we have received these forms, we will request your
medical records for the past 12 months.
You have 90 days to complete the Disability Medicaid application process. All requested verifications are due by
11-28-2016. If you need more time to complete the application process, have questions or need help completing
these forms, call the Disability Medicaid Determination team Monday through Friday, 8:00 a.m. to 5:00 p.m., at
801-245-4848 or toll-free at 1-877-824-6531.
Mail your verifications to:

Department of Workforce Services

Imaging Operations
P.O. Box 143245
Salt Lake City, UT 84114-3245

Fax to:

Toll Free: 1-877-313-4717

Salt Lake City Area: 801-526-9500

Please write your name and case number on all verifications you send.
<1360>

Toll free:

1-866-435-7414

Phone Number: 801-526-0950

Toll free FAX: 1-877-313-4717

FAX:

801-526-9500

DWS-ESD 114R
Rev. 06/2015

State of Utah
Department of Workforce Services
AUTHORIZATION TO RELEASE
HEALTH INFORMATION

Case number:

PID:

E32116366310102:7131026
R VASQUEZ

Purpose of the disclosure: Disabled Medicaid application

Customer name:
Social Security Number:

Date of birth:
(month / day / year)

I,

hereby authorize
Customer or authorized representative

Individual or organization releasing the information

Individual or organization releasing the information continued

to release specific health information from the records of the above named customer to the Utah
Department of Health, through its Division of Health Care Financing or the Department of Workforce
Services (DWS).
The specific health information authorized for release is: All medical and psychiatric/psychological
records, treatment plans, test results, evaluations, X-rays, lab results, emergency services,
consultations, diagnoses, clinical records, HIV/AIDS and STDs diagnoses and/or testing, genetic
testing, substance abuse/chemical dependency diagnoses and/or treatment records, which are both
contained within or separate from mental health records.
From

to the expiration of the authorization.

Date

I understand that this authorization will expire on the following date, event, or condition: One year from
the date of signature or a decision of the Medical Review Board. Or expiration date
chosen by customer:

I understand that if I fail to specify an expiration date or condition, this authorization is valid for
the period of time needed to fulfill its purpose.

I understand that I may revoke this authorization at any time, by sending written notification to
DWS. I understand that a revocation is not effective to the extent that the Division of Health Care
Financing or DWS has relied on the released health information.

I understand my rights and responsibilities indicated in the Notice of Privacy Practices already
provided to me. (For a duplicate Notice of Privacy Practices, go to:
http://health.utah.gov/hipaa/privacy.htm.)

I understand that I may refuse to sign this authorization. I also understand that the Division of
Health Care Financing or DWS cannot deny or refuse to provide treatment, payment, enrollment
in a health plan, or eligibility for benefits if I refuse to sign this authorization.

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I understand that once information is released pursuant to this authorization,

it is possible that it will no longer be protected by medical privacy laws and
could be disclosed by the person or agency that receives it.

Note: IDWS does not disclose controlled documents without consent of the
DWS Legal Department.

E32116366310202:7131026
R VASQUEZ

By signing, I acknowledge I have been provided a copy of this signed authorization.

Signature of customer or authorized representative

Date

Signature of parent or guardian, if under age 18

Date

If signed by an authorized representative, a description of authority to serve:

RELEASE PROTECTED MEDICAL INFORMATION TO:

Department of Workforce Services
DMD Team, PO Box 31431, Salt Lake City, Utah 84131
PHONE: (801) 245-4848 TOLL FREE (877) 824-6531 FAX: (801) 526-9339

Equal Opportunity Employer Program

Auxiliary aids and services are available upon request to individuals with disabilities by calling (801) 526-9240. Individuals
with speech and/or hearing impairments may call Relay Utah by dialing 711. Spanish Relay Utah: 1-888-346-3162

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DWS-ESD 354

State of Utah
Department of Workforce Services
MEDICAID DISABILITY ADDENDUM

Rev. 03/2015

Disability Medicaid Team

DMD Specialist

Return Address:

DWS/DMD
Midvale CIU 500
PO Box 31431
SLC, UT 84131-9988

E32116366320105:7131026
R VASQUEZ

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 applicants 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 number listed above.
Applicants Information
1. Name:
First

SS#:
Middle

Last

Birth Date:

Phone#:

Address:
Street

City

State

ZIP

2. What is the applicants disabling condition? (Describe the illness or injury in your own words.)

3. Has the applicant ever applied for, received or been denied disability by the Social Security
Administration?
Yes
No If the applicant has applied, list date of application:
If currently receiving, list date of first payment:
If denied, when?

Why denied?

Is the applicant currently appealing a Social Security denial?

Yes

No

If the applicant is a child, please disregard questions 4 and 5. Use questions 12 and 13 for description of
current activities.
4. When did the condition prevent the applicant from working? Month:

Year:

5. Work History List the jobs the applicant has had in the past 15 years. Use a separate sheet if necessary.
Dates Worked
Job Title
Days per
(Month and Year)
Name or Type of Company
(List most recent job first, include job
Week
duties/tasks)
From
To

Page 1

6. Education What is the highest school grade completed and when? (month/year)

List any special training (trade schools, technical courses, etc.)

E32116366320205:7131026
R VASQUEZ

7. Indicate the doctor/facility that has the latest medical records about the applicants disabling condition.
Doctor:

Phone#:
First

Last

Facility name (if applicable):

Address:

FAX#:

Street

City

State

Zip

How often does the applicant see this doctor?

Date applicant first saw this doctor:
Date applicant last saw this doctor:
Reason for visit? (Show illness or injury for which applicant had an examination or treatment.)

8. List any other doctors the applicant has seen in the last 12 months:
Doctor:

Phone#:
First

Last

Facility name (if applicable):

Address:

FAX#:

Street

City

State

Zip

How often does the applicant see this doctor?

Date applicant first saw this doctor:
Date applicant last saw this doctor:
Reason for visit? (Show illness or injury for which applicant had an examination or treatment.)

Doctor:

Phone#:
First

Last

Facility name (if applicable):

Address:

FAX#:

Street

City

State

Zip

How often does the applicant see this doctor?

Date applicant first saw this doctor:
Date applicant last saw this doctor:
Reason for visit? (Show illness or injury for which applicant had an examination or treatment.)

9. List the hospitals where the applicant has been treated in the last 12 months:
Name of hospital or clinic:
Address:
Street

Date of admission:

Phone#:
FAX#:
City

Date of discharge:

State

Zip

Date of outpatient visits:

Reason for visit? (Show illness or injury for which applicant had an examination or treatment.)
Page 2

10. Other agencies/programs the applicant is involved in:

(Voc Rehab, Mental Health, VA, SSI, etc.)
Name of Agency

Date of
Visit(s)

Address

E32116366320305:7131026
R VASQUEZ

11. Has the applicant had any of the following tests or procedures in the last year?
Name of Test

Check Box

Electrocardiogram and/or exercise test

Yes

No

X-Rays (Indicate areas chest, knee, etc.)

Yes

No

Breathing Tests

Yes

No

Blood Tests

Yes

No

Surgery/Biopsy (Describe)

Yes

No

Other (Specify)

Yes

No

When (Date)

Where (Facility Name)

If more space is needed to list other doctors, hospitals, agencies, etc., use a separate sheet.
INFORMATION ABOUT APPLICANTS ACTIVITIES
12.

Describe the applicants current activities in the following areas. How much/often are they performed?

Household Maintenance: (For example: cooking, cleaning, shopping, paying bills, and performing odd jobs
around the house as well as any other similar activities.)

Social Contacts: (For example: visits with friends, relatives, neighbors, attending church, parties, etc.)

Recreational Activities and Hobbies: (For example: hunting, fishing, bowling, hiking, playing musical
instruments, eating out, playing cards or board games, going to movies or watching television, etc.)

Other:

Page 3

13.

Use this section for additional information to answer questions from previous
sections or if you are applying for a child, use this space to compare the child's
activities and abilities to other children the same age.

E32116366320405:7131026
R VASQUEZ

Completed By:
Signature

Date

If completed by person other than applicant, indicate relationship to applicant:

Equal Opportunity Employer Program

Auxiliary aids and services are available upon request to individuals with disabilities by calling (801) 526-9240. Individuals with speech and/or
hearing impairments may call Relay Utah by dialing 711. Spanish Relay Utah: 1-888-346-3162.
Page 4

STOP

E32116366320505:7131026
R VASQUEZ

THIS PAGE TO BE COMPLETED BY SOMEONE WHO HAS

KNOWLEDGE OF THE APPLICANTS LIMITATIONS. FOR
EXAMPLE: CASE WORKERS, COUNSELORS, HEALTH
AIDES, CLERGY, TEACHERS, RELATIVES, ETC.
NOTE: MEDICAL PROVIDERS WILL NOT BE REIMBURSED FOR COMPLETING THIS PAGE.
OBSERVATIONS: Check any areas where difficulties were observed.
Yes
No
Reading
Seeing
Yes
No
Writing
Using Hands
Yes
No
Hearing
Sitting
Yes
No
Understanding
Walking
Yes
No
Answering
Balance
Yes
No
Breathing
Other (Specify)

Yes
Yes
Yes
Yes
Yes

No
No
No
No
No

If any of the above items were checked yes, describe in detail the difficulty observed:

Does the applicant speak English?

What are the applicants current living arrangements, i.e. lives independently in a home,
apartment, etc., or requires assistance, lives with relative, friend, in a group home, etc.?

Please describe the applicants ability to function, i.e. ability to understand, remember and
follow instructions. Can he/she care for personal needs, shop, manage funds, pay bills?
Can he/she interact successfully with others?

If you are filling out this form or gathering additional information on behalf of the applicant,
then list your name, address, phone number and relationship of the individual.

Yes

No If no, what language is spoken?

Completed By:
Signature

Date

Relationship to Applicant:
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