Developmental Disability Determination Application - Alaska Department Of Health And Social Services Page 4

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Use the space below if you would like to provide a narrative description to
supplement or enhance the required documentation of functional limitations
STATE USE ONLY
INITIAL REVIEW
Approved/ Date:____________
Denied / Date: ____________
Time Limited/ Date: __________
: _______________________
Date Determination Letter Sent
Health Program Manager Signature: ___________________________________________________________________
RESUBMISSION REVIEW
Approved/ Date:____________
Denied / Date: ____________
Time Limited/ Date: __________
: _______________________
Date Determination Letter Sent
Health Program Manager Signature: ___________________________________________________________________
MANAGER REVIEW
Approved/ Date:____________
Denied / Date: ____________
Time Limited/ Date: __________
: _______________________
Date Determination Letter Sent
Unit Manager Signature: ___________________________________________________________________
IDD-01 DDD Application Rev. 12-18-15
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