Approved Division of Senior and Disabilities Services (SDS) Forms
Continuously updated forms for SDS
Overview
Most SDS Approved Forms (except for those noted with asterisks *) are fillable PDFs. Forms marked with an asterisk are Word or Excel documents.
To reduce the chance of forms not working correctly, we recommend that all forms be downloaded and saved before being filled out for printing or electronic submission.
For assistance with reading or completing any of these forms, please contact the Policy Unit at HSS.DSDS.Policy@alaska.gov.
Specific programmatic questions about a particular form should be addressed to staff in the relevant SDS program.
Reminder: Please check the SDS Approved Forms webpage frequently for the most current versions of forms, as SDS makes improvements to its program forms continuously.
Approved Forms
Adult Protective Services Forms
Adult Protective Services Forms
NFLOC (ALI/APDD/CCMC) Waiver Program Forms
NFLOC (ALI/APDD/CCMC) Waiver Program Forms
Community First Choice Forms
Community First Choice Forms
- CFC-07/PCS-10 Representative Designee
- CFC-06 Application for Community First Choice
- CFC-01/PCS-03
- Amendment to PCS Service Plan (New 6/29/2022)
- CFC-02/PCS-15 Application for Community First Choice Personal Care Services When Traveling
- CFC-03/PCS-16 Notification of Transfer Form (revised 3/25/2022)
- CFC-04/PCS-07 Consumer/Legal Representative Agreement
- CFC-05/PCS-02 Personal Care Services/CFC Personal Care Services Request for Passive Range of Motion
Environmental Modification Forms for All Waivers
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
General Relief Forms
Harmony Access Forms
Harmony Access Forms
ISW/IDD Waiver Program Forms
ISW/IDD Waiver Program Forms
- IDD-01 Eligibility Determination and Request for Services Application
- IDD-03 ICAP Assessment Information and Consent- (Revised 6/28/23)
- 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- (Revised 6/28/23)
- 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
Long Term Care Forms
Material Improvement
Material Improvement
PCS (Personal Care Services) Participant Application and Service Request Forms
PCS (Personal Care Services) Participant Application and Service Request Forms
- PCA-02/CFC-05 Personal Care Services/CFC Personal Care Services Request for Passive Range of MotionPCA-03/CFC-01 PCS 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
- PCS-10 PCS Representative Designee
- PCS-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
- PCS-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: Removed (Care Coordinators should report Recipient Change of Status using note in Harmony within the demographics tab.)
- Uni-12 Request for Expedited Consideration
Provider Certification Forms
Provider Certification Forms
Provider Certification Tools:
- Resume Example
- Organization Chart Example
- Cert-50 QIR Quality Improvement Report Example (New 10/2/20)
- Provider Certification Application Guidance
- Cert-01 Waiver Services Provider Certification Application (Revised 5/8/2024)
- Cert-02 Care Coordinator Certification Application (Revised 4/8/24)
- Cert-03 Worker Assurances (Revised 4/8/24)
- Cert-04 Notice of Appointment or Change of Program Administrator (Revised 4/10/24)
- Cert-05 Service Declaration: Nursing Oversight and Care Management (Revised 4/10/24)
- Cert-06 Service Declaration: Care Coordination Services (Revised 4/10/24)
- Cert-07 Service Declaration: Chore Services (Revised 4/10/24)
- Cert-08 Service Declaration: Adult Day Services (Revised 4/15/24)
- Cert-09 Service Declaration Residential Supported Living Services (Revised 4/15/24)
- Cert-10 Service Declaration: Day Habilitation Services (Revised 4/15/24)
- 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: Employment Services (Revised 4/15/24)
- Cert-15 Service Declaration: Intensive Active Treatment Services (Revised 4/23/24)
- Cert-16 Service Declaration: Respite Care Services (Revised 4/15/24)
- Cert-17 Service Declaration: Transportation Services (Revised 4/23/24)
- Cert-18 Service Declaration: Meal Services (Revised 4/23/24)
- Cert-19 Service Declaration: Environmental Modification Services
- Cert-20 Care Coordinator Disclosure of Business and Familial Relationships (Revised 5/03/24)
- Cert-36 Personal Care Services Provider Certification Application (Revised 5/8/2024)
- Cert-37 Provider Certification Assurance on Policies (Revised 5/03/24)
Provider Certification Miscellaneous Forms
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
Universal Program Forms
Universal Program Forms
- * Uni-02 Support Plan for all Waivers and CFC (Removed 8/3/23, now done in Harmony)
- * Uni-03 Plan of Care Amendment all Waivers (Removed 8/3/23, now done in Harmony)
- * Uni-04 Application for ALI/APDD/CCMC/CFC (Removed. As of 10/01/22, use the NFLOC-04 or the CFC-06)
- Uni-05 Appointment for Care Coordinator/Targeted Case Management Services (Revised 8/7/24)
- Uni-07 Recipient Rights and Responsibilities
- Uni-08 Fair Hearing Rights Notice (effective Oct. 1, 2024)
- Uni-09 Verification of Diagnosis
- UNI-10: Removed (SDS no longer approves exceptions to monthly visits by Care Coordinators.)
- UNI-11: Removed (Care Coordinators should report Recipient Change of Status using note in Harmony within the demographics tab.)
- Uni-12 Request for Expedited Consideration
- * Uni-14 Services Overview and Cost Sheet (all waivers) (removed 1/31/2023, now done in Harmony)
- * Uni-14A ISW Services Overview and Cost Sheet (removed 1/31/2023, now done in Harmony)
- * Uni-14B CFC Services Overview and Cost Sheet (removed 1/31/2023, now done in Harmony)
- Uni-15 Person Centered POC Questionnaire
- 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
- Uni-20 24-Hour Care Calendar