Alaska Pregnancy Verification Form

Pregnant women living in the State of Alaska may have this form signed by a medical provider to verify their pregnancy claim.

Extracted Text for Proper Search

IS PREGNANT WITH AN ESTIMATED DELIVERY DATE OF.
MEDICAL PROVIDER SIGNATURE:
(Doctor, Nurse, Medical Practitioner, etc.)
PRINTED NAME:
TITLE:
DATE:TO MEDICAL PROVIDER:   PLEASE COMPLETE THIS FORM AND RETURN IT TO YOUR PATIENT, OR SEND THE COMPLETED FORM TO THE DIVISION OF PUBLIC ASSISTANCE OFFICE.GEN 30  06-3710 (10/88)(Please print patient's name)THIS IS TO VERIFY THAT DEPARTMENT OF HEALTH & SOCIAL SERVICESSTATE OF ALASKA
DIVISION OF PUBLIC ASSISTANCE
PREGNANCY VERIFICATION