Approved SDS Forms

Please Note: SDS is continuously making improvements to its many program forms so please check back frequently to ensure the most current version is utilized. You can refer to the “Revision Date” printed on the bottom left margin of each form to determine appropriate precedence. Specific programmatic questions about a particular form should  be addressed to the associated SDS program staff. Forms are posted as Microsoft Word and PDF user friendly documents that can be downloaded, saved and filled out for printing or electronic submission. Contact the DHSS webmaster if problems are encountered accessing forms as posted.

Please note, the forms with an asterisk * need to remain interactive in Word or Excel so do not meet section 508 information and communication technology (ICT) compliance standards. For assistance with reading or completing any of these forms, please contact the Policy Unit at HSS.DSDS.Policy@alaska.gov.

COVID-19 Forms

Community First Choice Forms

Universal Program Forms

IDD Waiver Program Forms

ALI/APDD/CCMC Waiver Program Forms

Environmental Modification Forms for All Waivers

Adult Protective Services Forms

General Relief Forms

PCA Participant Application and Service Request Forms

Provider Certification Forms 

Material Improvement

Telehealth

Long Term Care Forms

TABI Forms

COVID-19 Forms

• *COVID-19 Appendix K Person Centered Support Plan Request (revised 4/13/20)
• Instructions for Completing the COVID-19 Appendix K Person Centered
  Support Plan Request (revised 4/28/20)
• *COVID-19 Uni-14 Service Plan and Cost Sheet (revised 7/1/20)
• *COVID-19 Uni-14A (for ISW) Service Plan and Cost Sheet (revised 7/1/20)

Universal Program Forms

• * Uni-02 Support Plan for all Waivers and CFC
• * Uni-03 Plan of Care Amendment all Waivers
• * Uni-04 Application for ALI/APDD/CCMC/CFC
  
• Uni-05 Appointment for Care Coordinator/Targeted Case Management Services
• Uni-07 Recipient Rights & Responsibilities
• Uni-08 Notice of Adverse Action & Fair Hearing Rights
• Uni-09 Verification of Diagnosis 
  
• Uni-10 Care Coordination Request for Visit Exception
• Uni-11 Recipient Change of Status, All Programs
• Uni-12 Request for Expedited Consideration
  
• *Uni-14 Services Overview & Cost Sheet (all waivers) ​(revised 1/1/21)
• *Uni-14A ISW Services Overview and Cost Sheet (revised 1/1/21)
• *Uni-14B CFC Services Overview and Cost Sheet (revised 1/1/21)
• Uni-15 Person Centered POC Questionnaire
  
• Uni-16 Authorization for Release of Information 
• Instructions for completion UNI-16 Authorization for Release of Information
  
• DHSS-06-5872 Revocation of Authorization for Release of Information
• Uni-17 NOCM Care Provider Training Checklist (revised 12/29/2020)
• Uni-18 NOCM Nursing Care Plan (revised 1/10/2021)
  
• List of acceptable CPR and First Aid courses taught by licensed/certified agencies

ISW/IDD Waiver Program Forms

• IDD-01 Eligibility Determination and Request for Services Application
• IDD-03 ICAP Assessment Information and Consent
  
• IDD-04 Developmental Disa​bilities Registration and Review​​ 
• IDD-06 Guidelines for ICAP Process
• * IDD-08 DHSS Table of ICAP scores
• IDD-10 Interim ICF/IID Level of Care
  
• IDD-11 ICF/IID Level of Care Determination
  
• IDD-12 Guidelines for QDC Form
• IDD-13 Qualifying Diagnosis Certification Form
• IDD-14 Request for QDC
• IDD-15 Request for Exception, Day Habilitation In-Residence
ISW/IDD Initial and Renewal ICAP Application Checklist
ISW/IDD Initial Renewal ​Interim Application Checklist

• DHSS 06-5870 Release of Information
  

ALI/APDD/CCMC Waiver Program Forms

• Uni-09 Verification of Diagnosis
• * Uni-04 Application for ALI/APDD/CCMC/CFC
  
ALI/APDD/CCMC Initial Application Checklist
ALI/APDD/CCMC Renewal Application Checklist

Environmental Modification Forms for All Waivers
As of February 21, 2020 the Envionmental Modification Forms are in compliance with Section 508 of the Rehabilitation Act of 1973.

• Environmental Modification Services Conditions of Participation
  
• EM-01 EMOD Review Tool (Guide for EM planning)
• EM-02 Property Owners Consent to Environmental Modification
• EM-03 Request for Cost Estimate-Bathroom Accessibility
• EM-04 Request for Cost Estimate-Blank
• EM-05 Request for Cost Estimate-Door Accessibility
• EM-06 Request for Cost Estimate-Elevated Toilet with Grab Bars
• EM-07 Request for Cost Estimate-Hand Rails and Grab Bars
• EM-08 Request for Cost Estimate-Ramp Access
• EM-09 Request for Cost Estimate-Ramp Cover
• EM-10 Request for Cost Estimate-Roll In Shower
• EM-11 Request for Cost Estimate-Stair Lift
• EM-12 Request for Cost Estimate-Vertical Lift
• EM-14 Request to Select Cost Estimate other than Lowest

Adult Protective Services Forms

• APS-01 Report of Harm
  
• Uni-16 Authorization for Release of Information
  ~ Instructions for completion of UNI-16 Authorization for Release of Information
  

General Relief Forms
As of February 24, 2020, the APS Forms and the General Relief Forms are in compliance with Section 508 of the Rehabilitation Act of 1973.

• GR-01 Initial Application for General Relief Assisted Living Care
• GR-02 Renewal Application for General Relief Assisted Living Care
• GR-04 GR for ALC Client Activity Form

PCA Participant Application and Service Request Forms

• PCS-02/CFC-05 Personal Care Services/CFC Personal Care Services Request for Passive Range of Motion 
• PCS-03 Personal Care Services Amendment to Service Plan
• PCS-07/CFC-04 Consumer/Legal Representative Agreement
• PCS-08 PCA Application (revised 12/28/20)
  ~ Instructions for completing PCA-08 application (revised 12/30/20)
• PCS-08-A PCA Renewal Application (revised 12/30/20)
  ~ Instruction for completing PCA-08-A renewal application (revised 12/30/20)
  
• PCS-09 Limited Power of Attorney
• PCS-10 PCS Representative Designee 
• PCS-12 Request for Waiver of In-Person Review of Services
• PCS-13 First Aid Training Verification – Suggested Format
• PCS-14 Notice Of Use Of Private Health Care Information
• PCS-15/CFC-02 Application for Personal Care Service When Traveling
• PCS-16/CFC-03 Notification of Transfer Form
• PCS-17 Shared Agency Service Agreement​
• Uni-07 Recipient Rights & Responsibilities
  
• Uni-09 Verification of Diagnosis
• Uni-11 Recipient Change of Status, All Programs
• Uni-12 Request for Expedited Consideration
  

Community First Choice Forms

• CFC-01 Amendment to Service Plan  
• CFC-02/PCS-15 Application for Community First Choice Personal Care Services When Traveling  
• CFC-03/PCS-16 Notification of Transfer Form
  
CFC Only Initial Application Checklist
CFC Only Renewal Application Checklist

• CFC-04/PCS-07 Consumer/Legal Representative Agreement
• CFC-05/PCA-02 Personal Care Services/CFC Personal Care Services Request for Passive Range of Motion 
• Supplemental Cover Sheet for CFC Services
  (Temporary form to be used pending revision of Uni-04 in 2021)
  

Provider Certification Forms

• Provider Certification Tools:
  (Resume Example)  (Organization Chart Example)
  (Cert-50 QIR Quality Improvement Report Example) (New 10/2/20)
• Cert-01 Waiver Services Provider Certification Application
• Cert-02 Care Coordinator Certification Application 
• Cert-03 Worker Assurances
• Cert-04 Notice of Appointment or Change of Program Administrator
• Cert-05 Service Declaration: Nursing Oversight & Care Management
• Cert-06 Service Declaration: Care Coordination Services
• Cert-07 Service Declaration: Chore Services
• Cert-08 Service Declaration: Adult Day Services
• Cert-09 Service Declaration Residential Supported Living Services
  
• Cert-10 Service Declaration: Day Habilitation Services
• Cert-11 Service Declaration: Residential Habilitation Services
• Cert-12 Group Home Habilitation Site Information/Change of Status Report
• Cert-13 Family Home Habilitation Site Information/Change of Status Report
• Cert-14 Service Declaration: Supported Employment Services
• Cert-15 Service Declaration: Intensive Active Treatment Services
• Cert-16 Service Declaration: Respite Care Services
• Cert-17 Service Declaration: Transportation Services
• Cert-18 Service Declaration: Meal Services 
• Cert-19 Service Declaration: Environmental Modification Services
• Cert-20 Care Coordinator Disclosure of Business and Familial Relationships
• Cert-36 Personal Care Services Provider Certification Application
• Cert-37 Provider Certification Assurance on Policies

Provider Certification Misc. Forms

• Cert-41 Provider Certification Application for Additional Service
  
• Cert-42 Report of change: Provider Agency Information
• Cert-44 Report of Change: Care Coordinator Information
  
• Cert-46 Care Coordination Agency Certification Conflict of Interest Attestation
• Cert-47 Individual Care Coordinator Conflict of Interest Assurance
• Cert-48 Conflict of Interest Exception Application
• Cert-49-A  FA/CPR Waiver for First Time Personal Care Assistants
• Cert-49-B  FA/CPR Remote Allowance for Continuing Personal Care Assistants
• Cert-50-QIR Quality Improvement Report Template (New 10/2/20)

Material Improvement

• MI-01 Material Improvement for ALI/APDD
• MI-02 Material Improvement for CCMC 
• MI-03 Material Improvement for IDD Recipients Age 3 and Older
• MI-04 Material Improvement for IDD Recipients Under Age 3

Teleassessment

• TELE-01 Environmental Questionnaire
• TELE-02 Consent for Teleassessment
• TELE-02A Consent for IDD Teleassessment
  

Long Term Care Forms

• LTC-01 Long Term Care Facility Authorization
• LTC-02 Pre-Admission Screening and Resident Review
• LTC-03 Nursing Facility Transition Grant Application
  

TABI Forms

• TABI-01 Mini-grant application
• TABI-02 TABI Verification of Diagnosis

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 Updated 1/6/2021