Get Ad #2 Form - Dpaweb - Dpaweb Hss State Ak

Filling out the AD #2 Form is an important step for individuals applying for Interim Assistance benefits from the State of Alaska. This guide will provide you with a clear, step-by-step process to successfully complete the form online.

Follow the steps to fill out the AD #2 Form accurately online.

1. Select the ‘Get Form’ button to access the AD #2 Form and open it for editing.
2. Enter the information required in the DPA Use Only section, including the ET Name, Phone number, DPA Office, and FAX number.
3. In the Client section, fill in the Social Security Number (SSN) and EIS Case number, if applicable.
4. Indicate whether the application has been approved by selecting the corresponding checkbox for 'Yes' or 'No'.
5. Provide the applicant's name and birth date in the respective fields to identify the individual applying for Interim Assistance.
6. As a physician or authorized medical professional, verify the applicant's medical condition by checking the appropriate box from the list provided.
7. Answer questions regarding the applicant's diagnosis and expected recovery time by selecting 'Yes' or 'No', and indicating the expected length of time for recovery.
8. Include any additional relevant information about the applicant's condition in the provided space.
9. Ensure that you attach any relevant medical records or test results that are necessary to confirm the applicant's diagnosis.
10. Sign and date the form, then provide your printed name, type of practice, address, and phone number to complete the submission.
11. After filling out the form, save your changes, then download, print, or share the completed AD #2 Form as needed.

Complete your form online today to ensure timely processing of your application.