Utah DWS Medicare Savings Application: Form 61 and Documents Needed

DWS Form 61 is a 20-page application that covers everything from food assistance to child care. If all you need is a Medicare Savings Program, most of it doesn't apply. Here's what matters.

Form 61: The Only Application Form

Utah uses a single application form — Form 61 (Application for SNAP, Financial Assistance, Child Care, and Medical Assistance) — for all DWS benefit programs. There is no separate Medicare Savings Program form. You check "Medical Assistance" and focus on the income, asset, and household sections.

Download it at jobs.utah.gov/forms/61app.pdf, or complete it digitally through the myCase portal at jobs.utah.gov/mycase.

Submission options:

• Mail: DWS Medical Processing Office, P.O. Box 143245, Salt Lake City, UT 84114-3245
• Fax: (801) 526-9505
• In person: Any DWS Employment Center
• Online: myCase portal (guided digital version of the same form)

Documents DWS Needs

DWS runs electronic checks against SSA databases, state wage records, and the Asset Verification System before asking for paper. But they often need supplemental documentation, especially for bank accounts and pensions. Gather these before submitting:

Identity and Medicare status:

• Government-issued photo ID
• Medicare card (red, white, and blue) or an SSA award letter confirming Part A entitlement

Income verification:

• Social Security Award letter showing the gross monthly benefit amount — not the deposit amount, which has Part B already deducted
• Private pension or annuity statements showing gross monthly payouts
• Pay stubs if your parent has any earned income

Asset verification:

• Bank statements for all checking, savings, and CD accounts covering 30–60 days
• Life insurance policy face value documentation (only if aggregate face value exceeds $1,500)
• Documentation of retirement account distributions

Residency:

• Utility bill, lease agreement, or other proof of Utah residence

Verification Timelines

If DWS can't confirm reported figures electronically, they issue a written Request for Information. The clock is tight: 10–15 days to respond. Missing the deadline can result in a denial based on insufficient documentation, not on income or assets.

DWS must issue a final eligibility decision within 45 calendar days of receiving a signed application. Disability-based applications get 90 days.

Filing for a Parent (Form 114AR)

If you're managing the application for an aging parent, file Form 114AR (Authorization to Disclose Medical Eligibility Information / Appoint Authorized Representative) alongside the application. This lets you:

• Talk to DWS caseworkers on your parent's behalf
• Receive official written notices
• Upload documents through your own myCase login
• File appeals if needed

For Social Security matters (Extra Help, Medicare enrollment), file a separate SSA Form SSA-1696 at the local SSA field office.

What DWS Does with the Application

DWS doesn't ask which MSP you want. They evaluate income and resources against QMB, SLMB, and QI thresholds and award the most beneficial program your parent qualifies for. If they qualify for full Medicaid as well, DWS may assign QMB-Plus or SLMB-Plus, which adds full Medicaid benefits.

The Utah Medicare Savings Programs & Extra Help Guide provides a section-by-section walkthrough of Form 61 for MSP-only applicants, document preparation checklists, and timeline tracking tools for the verification process.

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