Approved SDS Forms

Please Note: SDS continuously make improvements to its program forms. Please check back often for the most current version. 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.

As of May 13, 2020, all SDS Approved Forms except for those noted with asterisks * are fillable PDFs that are in compliance with Section 508 of the Rehabilitation Act of 1973.

Please note, the forms with an asterisk * need to remain interactive in Word or Excel and 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

Form Categories

• Adult Protective Services Forms
• NFLOC (ALI/APDD/CCMC) Waiver Program Forms
• Community First Choice Forms
• COVID-19 Forms
• Environmental Modification Forms for All Waivers
• General Relief Forms
• Harmony Access Forms
• IDD Waiver Program Forms
• Long Term Care Forms
• Material Improvement
• PCA Participant Application and Service Request Forms
• Provider Certification Forms
• TABI Forms
• Telehealth
• Universal Program Forms

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

NFLOC (ALI/APDD/CCMC) Waiver Program Forms

• NFLOC-04 Application for ALI/APDD/CCMC
  • NFLOC-04 Instructions
  • NFLOC Provider Request Inquiry Checklist
  • NFLOC Initial Application Checklist
  • NFLOC Renewal Application Checklist
• Uni-09 Verification of Diagnosis

Community First Choice Forms

• CFC-06 Application for Community First Choice
  • CFC-06 Instructions
  • CFC Initial Application Checklist
  • CFC Renewal Application Checklist
• CFC-01/PCA-03 (New 6/29/2022)
• CFC-02/PCS-15 Application for Community First Choice Personal Care Services When Traveling
• CFC-03/PCA-16 Notification of Transfer Form (revised 3/25/2022)
  • CFC Provider Request Inquiry Care Coordinator Checklist (New 10/01/2021)
  • CFC Provider Request Inquiry PCA Agency Checklist (New 10/01/2021)
• 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

COVID-19 Forms

• * COVID-19 Appendix K Person Centered Support Plan Request (Word) (revised 4/13/20)
  • Instructions for Completing the COVID-19 Appendix K Person Centered Support Plan Request
    (revised 4/28/20)

Environmental Modification Forms for All Waivers

• 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

General Relief Forms

• 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
  • * GR ALH Providers 11/29/2021 (Excel) - Posted 8/24/2021

Harmony Access Forms

• Harmony Access Coordinator Agreement form
• Harmony Privacy and Security Agreement (Individual Provider User)

ISW/IDD Waiver Program Forms

• IDD-01 Eligibility Determination and Request for Services Application
• IDD-03 ICAP Assessment Information and Consent - (Revised 8/1/2022)
• ISW/IDD Initial and Renewal ICAP Application Checklist
  
• IDD-04 Developmental Disabilities Registration and Review
• IDD-06 Guidelines for ICAP Process
• * IDD-08 DHSS Table of ICAP scores
• IDD-10 Interim ICF/IID Level of Care
• ISW/IDD Initial Renewal Interim Application Checklist
  
• 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

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

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

PCA Participant Application and Service Request Forms

• PCA-02/CFC-05 Personal Care Services/CFC Personal Care Services Request for Passive Range of Motion
• PCA-03 Personal Care Services Amendment to Service Plan
• PCS-07/CFC-04 Consumer/Legal Representative Agreement
• PCA-08 PCA Application (revised 12/28/20)
  • Instructions for completing PCA-08 application (revised 12/30/20)
• PCA-08-A PCA Renewal Application (revised 12/30/20)
  • Instruction for completing PCA-08-A renewal application (revised 12/30/20)
• PCA-09 Limited Power of Attorney
• PCA-10 PCS Representative Designee
• PCA-12 Request for Waiver of In-Person Review of Services
• PCA-13 First Aid Training Verification
• PCA-14 Notice Of Use Of Private Health Care Information
• PCS-15/CFC-02 Application for Personal Care Service When Traveling
• PCA-16/CFC-03 Notification of Transfer Form (revised 3/25/2022)
• PCA-17/CFC-07 Shared Agency Agreement (New 6/29/2022)
• Uni-07 Recipient Rights and Responsibilities
• Uni-09 Verification of Diagnosis
• Uni-11 Recipient Change of Status, All Programs
• Uni-12 Request for Expedited Consideration

Provider Certification Forms

• Provider Certification Tools:
  • Resume Example
  • Organization Chart Example
  • Cert-50 QIR Quality Improvement Report Example (New 10/2/20)
  • Waiver Certification Application Guidance
  • PCS Provider Certification Application Guidance
• 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 and 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 Miscellaneous 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-45 Out of State Attestation (New 7/22/2022)
• 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)
• Cert-50-QUI Quality Improvement Report Example

TABI Forms

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

Teleassessment

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

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 (Expires 9/30/2022)
• Uni-05 Appointment for Care Coordinator/Targeted Case Management Services
• Uni-07 Recipient Rights and Responsibilities
• Uni-08 Notice of Adverse Action and 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 and Cost Sheet (all waivers) (revised 7/1/21)
  • * Uni-14A ISW Services Overview and Cost Sheet (revised 7/1/21)
  • * Uni-14B CFC Services Overview and Cost Sheet (revised 7/1/21)
• Uni-15 Person Centered POC Questionnaire
  
• Uni-16 Authorization for Release of Information
  • Instructions for completion UNI-16 Authorization for Release of Information
• Uni-17 ROI Revocation (revised 12/29/2020)
• Uni-18 NOCM Nursing Care Plan (revised 1/10/2021)
• Uni-19 Care Provider Training Checklist

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Updated 8/25/2021