Uplift Application

UTTHC Uplift Application

This form will help determine if you qualify for the Uplift program to receive a Utah Medical Card at reduced or no cost. This information is private and not shared. If you need help, call us at 801.851.5554.
Date / Time
Waitlist in progress

Uplift is working with a growing waitlist of qualified applicants. Please note that we will most likely be able to serve you about 4 months from the day you apply, but we will be in touch soon either way!
Name*

First NameLast Name
E-mail (use the same one you will use to register with the state).*
Phone Number*

Area CodePhone Number
Date of birth*

MonthDayYear
Date
converted Date of birth

YearMonthDay
Date
Age*
Zip Code*
Are you a legal Utah resident?*
Do you currently have a Utah Medical Card, or have you had one before?

No, this would be my first Utah Medical CardYes, I have an active card that I need to renewYes, I had a card before but it is expiredI'm not sure
When does your current Medical Card expire?

MonthDayYear
Date
My main complaint is:*
My OTHER complaint is:*
Sometimes {myOther} is caused by or can lead to other symptoms such as frequent headaches, nausea, or pain, which are qualifying conditions for Medical Cards in Utah. If this is true for you, please select one that applies.
Other Complaint
The options above are currently the only conditions listed as qualifying conditions for a Medical Card in Utah. If you feel you should be considered and you have a different condition, list it here.
Do you have active Medicaid coverage or a Terminal Illness?*

I have MedicaidI have a Terminal IllnessNeither
Terminal Illness is defined here as having a diagnosed life expectancy of less than six months or being under hospice care. Please briefly explain your terminal condition.
Please upload medical records with your condition or diagnosis listed. This will be reviewed by a Qualified Medical Provider.

Browse Files

Cancelof
Enter your Medicaid insurance member ID number
OR enter your Social Security Number.
This will only be used to verify your Medicaid status with the Department of Health.
To become an Uplift patient, you must either have a terminal condition or a Medicaid ID. If you believe you qualify for a Medicaid program, you can apply through the Department of Health and come back to us when you have a member ID number. Although you do not currently qualify for an Uplift subsidy, you may still qualify as a Med Card patient! Please give us a call to schedule an appointment with a $25 discount. 801.851.5554
To compensate our awesome clinic staff and medical providers, new patient Med Card evaluations typically cost $250. Uplift relies on donations to cover Med Card costs for patients like you. If you cover part of your appointment cost, we are able to assist to more patients. But it's also okay if you have no room in your budget! What amount are you able to pay at the time of your appointment?*
Anything else you'd like us to know?
Lissa Reed SF User ID (Owner)
Should be Empty:

UTTHC Uplift Application

Waitlist in progress