Fillable ~LASKA Department of Health and Social Services (State of Alaska)

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~LASKA Department of Health and Social Services (State of Alaska)

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The ~LASKA Department of Health and Social Services (State of Alaska) form is 1 page long and contains:

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  • 6 check-boxes
  • 8 other fields

Country of origin: US
File type: PDF

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STATE
0
~LASKA
GOVERNOR
MIKE
DUNLEAVY
Department of
Health and Social Services
OFFICER OF THE COMMISSIONER
Medicaid Program Integrity
4601 Business Park Blvd., Bldg. K
Anchorage, Alaska 99503-7167
Main: 907.269.0399
Fax: 907.269.3460
Medical Records Destroyed by a Disaster
Due to the earthquake disaster of November 30, 2018, I am unable to provide the requested medical documentation in
support of my Medicaid claim, TCN/Sample ID_________________ (please include TCN/Sample ID number).
I attest that the medical record documentation was:
__ completely destroyed on ___________(please include date).
__ partially destroyed on ____________(please include date); however, I am providing any remaining medical
record documentation.
The medical record documentation was destroyed by:
__ flood
__ fire
__ earthquake
__ other ___________________________________________.
Under penalty of law, I declare to the best of my knowledge and belief, that the information I have provided is true,
correct, and complete.
Please fill-in the following information:
Provider Name: ____________________________ Provider ID: _______________________
Printed Full Name: _________________________ Title: _____________________________
Signature: _______________________________ Date of Signature: ___________________
Please return form to: State of Alaska - Health and Social Services
Medicaid Program
Integrity
4601 Business Park Blvd., Bldg K
Anchorage, AK 99503-7167
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LASKA Department of Health and Social Services (State of Alaska)

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Completed 11 February 2021

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