1. (a) A person may apply for assistance for the diagnosis and treatment of a child under the program for children with disabilities if that person could legally consent to the provision of medical care to the child. To apply, a person shall use forms provided by the department and must submit the application to the department. If an application is not complete, the department, may either reject the application or assist the applicant in completing the application.

2. (b) An application must include

   1. (1) the name, address, and birthdate of the child with a disability for whom assistance is sought;
   2. (2) the name, home and business address, and telephone numbers of the applicant;
   3. (3) the name, address, telephone number, employment status, and employer of the child's parents or, if applicable, guardians, if the applicant knows this information;
   4. (4) the status of the child's eligibility for Medicaid, Alaska Native Health Service benefits, or other government entitlements;
   5. (5) the status of the child's coverage under any health or dental insurance policy, or under other insurance that might pay for treatment;
   6. (6) the number of persons in the child's family;
   7. (7) the gross income and resources and the allowable deductions of the child's family, as described at 7 AAC 23.180(b), for the 12-month period preceding the date of application;

   8. (8) a complete medical history of the child, including

      1. (A) a description of the present complaint;
      2. (B) the name of the child's physician;
      3. (C) the child's social and family history; and
      4. (D) other available medical information about the child's disability;
   9. (9) a release executed by the child's parent or guardian that allows the department to verify any information provided in the application and to secure reports of service provided through this program;
   10. (10) a description of any circumstances that are beyond the control of the child's family and that cause the family to be unable to pay for treatment of the disease or condition that causes the child to have a disability.
3. (c) The applicant or the child shall provide any and all reasonably available documentation or witnesses that the department, in its discretion, requests, to enable the department to verify the child's eligibility. The department will suspend a child's eligibility if the applicant or the child's family fails to provide proof of eligibility by clear and convincing evidence unless the department, in its discretion, finds good cause for the failure to cooperate.

4. (d) The department will consider the child's eligibility, and notify the applicant of

   1. (1) the child's eligibility status;
   2. (2) the eligibility status of the child's condition;
   3. (3) the health care provider, if any, to whom the department intends to refer the child;
   4. (4) the alternate resources that must be exhausted before the department will pay any costs;
   5. (5) the family participation amount for the succeeding twelve-month period; and
   6. (6) the beginning and ending date of the child's eligibility.

5. (e) To continue receiving assistance, an applicant shall reapply for assistance under the program for children with disabilities every two years. The applicant shall submit a new financial report containing the information described at (b)(4) - (7) of this section at least annually, or at any time that

   1. (1) the family's adjusted income for a calendar quarter, determined as described in 7 AAC 23.180(b)(1) - (6), varies by more than 25 percent from that of the same calendar quarter of the previous year; or
   2. (2) the department requests that a new form be completed.

(Eff. 6/28/85, Register 94)