State of Alaska • Department of Health and Social Services • Senior and Disabilities Services
Intellectual and Developmental Disabilities Unit
Anchorage Office: Phone: (907) 269-3666; Toll Free: 1-800-770-3930; Fax: (907) 269-3639
550 W. 8th Avenue, Anchorage, AK 99501
Fairbanks Office: Phone: (907) 451-5045; Toll Free: 1-800-770-1672; Fax: (907) 451-5046
751 Old Richardson Highway, Suite 100-A, Fairbanks, 99701
Developmental Disability Determination Application
Applicants can complete and submit this form, or get help with completing and submitting the form
from a STAR (Short Term Assistance and Referral) agency or an Aging and Disability Resource
Center (ADRC). To find one, visit
or
APPLICANT INFORMATION
Please note – the applicant is the individual for whom the Developmental Disability Determination is being sought
Name: _______________________ ____________________ ________________
Last Name
First Name
M.I.
Address: ________________________________
____________________________________________________
Street Address
Mailing Address (if different)
City: ___________________________________
State: _____________ Zip: _____________
Telephone Number: (_____) ________________
Sex: Male
Female
Date of Birth: _____________ Place of Birth: ______________ _____________
City
State
Name of Legal Representative*: ___________________________________________________________________
*Anyone other than the parent(s) of a minor child MUST include copies of documents that provide evidence of legal
authority to act on behalf of the applicant.
Legal Representative’s Address: ____________________________________________________________
City: __________________________ State: _____________ Zip: _____________
Home Telephone: ___________________ Work Telephone: __________________
Cell Telephone: _____________________ Email: ___________________________
If someone assisting you with this application should receive a copy of the determination letter, please provide the
information below. Please ensure that an Authorization for Release of Information is included for this person. Download
Release of Information forms here:
Name: _____________________________________ Relationship: ____________________________________
Contact: _____________________________________________________________________________________
IDD-01 DDD Application Rev. 12-18-15
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