Alaska Affidavit & Memorandum, SHC-1301 is a form issued by the Alaska Department of Health and Social Services (DSS). It is used to document the health care services provided to a patient under the Alaska Medical Assistance Program. The form includes a patient's name, date of birth, Medicaid number, and the name of the provider who provided the services. The form is typically signed by both the provider and the patient. There are two types of Alaska Affidavit & Memorandum, SHC-1301: 1. Medicaid Reimbursement Affidavit & Memorandum, SHC-1301: This form is used by a provider to submit a claim to Medicaid for reimbursement of services provided to a patient. 2. Non-Reimbursement Affidavit & Memorandum, SHC-1301: This form is used to document services provided to a patient that are not eligible for reimbursement under the Alaska Medical Assistance Program.
Alaska Affidavit & Memorandum, SHC-1301
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Affidavit & Memorandum, SHC-1301
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All fields in the affidavit must be completed accurately: • The actual date range of the medical record should be used. The applicant for a Texas driver license or identification card must complete Section A. A. Applicant Information. Name.Items 11 - 17 — Complete this affidavit as soon as pos- sible. Many creditors ask that you send it within two weeks. Fill out the FTC ID Theft Affidavit completely and accurately. Complete Sections A-F of this form. Complete the affidavit. ❑ Sign the Affidavit before a Notary Public. Whenever any legal papers are served, the person serving the papers must fill out a written form that says how the papers were served. This form is provided to help you determine if a sale qualifies for exemption.