Form IDD-14 "Request for Qualifying Diagnosis Certification" - Alaska

What Is Form IDD-14?

This is a legal form that was released by the Alaska Department of Health and Social Services - a government authority operating within Alaska. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on January 3, 2020;
  • The latest edition provided by the Alaska Department of Health and Social Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form IDD-14 by clicking the link below or browse more documents and templates provided by the Alaska Department of Health and Social Services.

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Download Form IDD-14 "Request for Qualifying Diagnosis Certification" - Alaska

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State of Alaska • Department of Health and Social Service • Senior and Disabilities Services
Request for Qualifying Diagnosis Certification
The Division of Senior and Disabilities Services (SDS) administers the home and community-based
Medicaid waiver program for individuals with Intellectual or Developmental Disabilities (IDD) as an
alternative to institutional care. One element of eligibility is a diagnosis that meets the regulatory
requirements in 7 AAC 140.600.
The attached Qualifying Diagnosis Certification form identifies an applicant for IDD waiver services.
Please complete the form if the applicant has one of the qualifying diagnoses, and include the corresponding
ICD-9 code. Sign and return the form to the applicant’s care coordinator, preferable by e-mail, at the
address below.
Care Coordinator contact information:
name (please print)
e-mail
phone
street address
city, state, Zip
Instructions
Only the following professionals, licensed to practice in Alaska, may complete this form:
 Physician
 Advanced Nurse Practitioner
 Physician’s Assistant
 Psychologist
 School Psychologist
 Psychological Associate
Please initial each box that applies to the application. Boxes with “X” or checks will not be accepted.
For questions or more information contact an SDS “Qualified Intellectual Disability Professional”:
 Northern Region: 451-5045 or 1-800-770-1672
 Southcentral Region: 269-3666 or 1-800-478-9996
IDD-14
Revised 7/2/2013
ADA 1/3/2020
State of Alaska • Department of Health and Social Service • Senior and Disabilities Services
Request for Qualifying Diagnosis Certification
The Division of Senior and Disabilities Services (SDS) administers the home and community-based
Medicaid waiver program for individuals with Intellectual or Developmental Disabilities (IDD) as an
alternative to institutional care. One element of eligibility is a diagnosis that meets the regulatory
requirements in 7 AAC 140.600.
The attached Qualifying Diagnosis Certification form identifies an applicant for IDD waiver services.
Please complete the form if the applicant has one of the qualifying diagnoses, and include the corresponding
ICD-9 code. Sign and return the form to the applicant’s care coordinator, preferable by e-mail, at the
address below.
Care Coordinator contact information:
name (please print)
e-mail
phone
street address
city, state, Zip
Instructions
Only the following professionals, licensed to practice in Alaska, may complete this form:
 Physician
 Advanced Nurse Practitioner
 Physician’s Assistant
 Psychologist
 School Psychologist
 Psychological Associate
Please initial each box that applies to the application. Boxes with “X” or checks will not be accepted.
For questions or more information contact an SDS “Qualified Intellectual Disability Professional”:
 Northern Region: 451-5045 or 1-800-770-1672
 Southcentral Region: 269-3666 or 1-800-478-9996
IDD-14
Revised 7/2/2013
ADA 1/3/2020