Division of Public Assistance Forms

• Denali KidCare Income Guidelines
• Med 4 - Application for Adults and Children with Long Term Care Needs
• Med 1 – Child’s Medical History and Disability Report
• Med 2 – Release of Information [Six (6) signed originals needed]
• Med 15 – TEFRA Brochure
• Social Security Disability Listings

Division of Senior and Disability Services Forms

• Qualifying Diagnosis Certification
• MRDD/TEFRA Programs Demographics Form

Care Coordinator Manual and Forms (submitted to QH by Care Coordinator)

• Care Coordinator Manual (Updated 2/09)
• TEFRA Medicaid Checklist
• ICF/MR Checklist – Children UNDER three (3) years old
• ICF/MR Checklist – Children OVER three (3) years old
• NF LOC Form
• IPH LOC Form
• Plan of Care (POC) Form
• Estimated Medical Expenses (COC) Form
• 24-hour Log

Care Coordinator Contact Lists

• Bethel Area CCs
• Kenai Peninsula CCs
• Kodiak CCs
• Northern Area CCs
• South Central CCs
• South East CCs

The documents available for download on this page are Adobe Acrobat® PDF files, which must be opened using the Adobe Acrobat reader. If you do not have the reader, you can get it FREE from the Adobe website.