Provider Resources

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 signed originals needed)
• Med 15 - Alaska Medicaid - 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 Qualis Health by Care Coordinator

• Care Coordinator Manual - current
• Alaska Medicaid - TEFRA Checklist
• ICF/MR Checklist (children UNDER three years old)
• ICF/MR Checklist (children OVER three years old)
• Nursing Facility Level of Care (LOC) Form
• Inpatient Psychiatric Hospital (LOC) Form
• Plan of Care (POC) Form
• Estimated Medical Expenses (COC) Form
• 24-hour Log

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