125-4          SUBMITTING INFORMATION AND CONTACTING THE MEDICAL REVIEWER

Once all the necessary forms are complete, the caseworker will provide the information and other supporting documents to the IAInterim Assistance Medical Reviewer.

FAX THE CLIENT PACKET TO THE IAInterim Assistance MEDICAL REVIEWER, INCLUDING:

• AD 2Preliminary Examination for Interim Assistance (Preliminary Examination for Interim Assistance)
• APA 4Disability & Vocational Report (Disability and Vocational Report)
• GEN 150Authorization for Release of Protected Health Information IAInterim Assistance (HIPAAHealth Insurance Portability and Accountability Act DHSSDepartment of Health and Social Services Authorization for Release of PHIProtected Health Information)
• Other supporting documents or medical records, if available.

IAInterim Assistance MEDICAL REVIEWER CONTACT INFORMATION:

IA Medical Reviewer

Division of Public Assistance

3601 C Street, Suite 460

Anchorage, AK 99503

Phone: (907) 269-0064

Fax: (907) 269-0962

hss.dpa.interim.assist@alaska.gov

Note:

Due to HIPAAHealth Insurance Portability and Accountability Act requirements, IAInterim Assistance packets must be sent to the IAInterim Assistance Medical Reviewer only by fax. The AD 2Preliminary Examination for Interim Assistance form (Preliminary Examination for Interim Assistance) also contains medical information as it is signed by a medical doctor and includes the applicant's diagnoses. For additional information about HIPAAHealth Insurance Portability and Accountability Act rules, refer to MS 100-8.

Note:

A blindness determination does not require further review of the IAInterim Assistance Medical Reviewer. If a caseworker receives an AB 3Review Report on Aid to the Blind (Reviewer Report on Aid to the Blind) form, the caseworker will accept the judgement of the medical provider as noted on the AB 3Review Report on Aid to the Blind. It is not reviewed by any other authority including the IAInterim Assistance Medical Reviewer.